Priority Setting & Resource Allocation Committee Minutes February 14, 2022

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Meeting of the Priority Setting & Resource Allocation Committee

Monday, February 14, 2022

By Zoom Videoconference

2:05 – 5:00

Members Present: Marya Gilborn (Co-chair), Jeff Natt (Co-chair), Fulvia Alvelo, Matt Baney, Paul Carr, Broni Cockrell, Billy Fields, Graham Harriman, Matthew Lesieur, Scott Spiegler (for Guadalupe Dominguez Plummer), Michael Rifkin, Leo Ruiz, Claire Simon, Terry Troia, Dorella Walters

Members Absent: Eunice Casey, Joan Edwards, Henry Nguyen, Victor Velazquez

Staff Present: David Klotz, Noelisa Montero, Gina Gambone, Grace Mackson, Francis Silva, Bryan Meisel José Colón-Berdecía, Kimbirly Mack, Scarlett Macias, Johanna Acosta, Karen Miller, Giovanna Navoa, Grace Herndon, Cullen Hunter, Tye Seabrook (NYC DOHMH); Gemma Barclay, Arya Shahi (Public Health Solutions)

Agenda Item #1: Welcome/Introductions/Minutes

Mr. Natt and Ms. Gilborn opened the meeting, followed by introductions and a moment of silence.  The minutes of the January 10, 2022 meeting were approved with no changes.  

Agenda Item #2: Review of the RWPA Portfolio: Mental Health Services (MSV)

Ms. Montero presented the 2020 fact sheet for MSV, a service category that provides treatment and counseling to individuals with HIV and mental illness, with or without co-occurring substance use disorders. The goal is to improve quality of life and mental health (MH) functioning; facilitate continued engagement in biological, psychological, and psycho-social care and treatment including adherence to ART and/ or psychotropic medications; and provide mental health navigation and coordination with primary care.  Enrollees are individuals diagnosed with mental illness or in need of MH services using DSM criteria; persons with co-occurring MH, substance use, and other medical conditions; individuals with physical, behavioral, psycho-social, or sensory impairments; and homeless/unstably housed or homebound PLWHA. 

Client demographics show that an overwhelming majority of clients are Black or Hispanic, and there is an over-representation of women compared to the general PLWH population.  Older PLWH and cisgender women of color are the most heavily served special populations.

Four years of service unit data shows that Client Engagement and Client Assistance are the most heavily used service types, followed by Treatment Adherence and Mental Health Counseling.  A very low number of psychiatric service units are used, mainly due to payer of last resort (POLR) issues.  As Medicaid and Medicare pay for most MH services, RWPA MSV mostly pays for wrap around services.  Three years of enrolment data show that the number of unduplicated clients has fallen from 748 in 2017 to 543 (for 11 months, prorated to 592) in 2019.  Spending has declined concurrently, falling from $4.45M in 2016 to $3.75 in 2018 (2019 data will be available after close-out).  In 2016, MHV as a category spent over 100% of their original allotted budget.  Over 2017 and 2018, MSV programs have spent less than the original allocation and increased the amount of client engagement and assistance activities while mostly maintaining the amount of direct MH services delivered.

DOHMH offers outpatient and psychiatric services as part of their Community Health Centers regardless of ability to pay or immigration status.  NYC HHC offer s emergency psychiatric services, treatment for mental illness and support f or clients recovering from substance use.  The NYS Office of Mental Health offers the PACT (Program for Assertive Community Treatment) program that provides psychiatric and general health care, supportive therapy, and resources to help client manage symptoms of their illness.  This funding also covers anti-psychotic and anti-depressant medications.  The NYS AI offers similar services as well as specialized services for women, children and adolescents.  ADAP Plus through NYS AI covers MH treatment in the context of HIV primary care.  An eligibility requirement for MH programs is to be Article 28 or 31 certified so they can bill allowable services to Medicaid and ensure RWPA services are truly utilized as a payer of last resort.

A summary of the discussion follows:

  • Nearly a third of enrolled clients had no service plan update, which should happen annually.  This may be because not all clients are enrolled for a full year.  
  • The modified allocations have are substantially lower than the original spending plan allocation and still underspent.  The category needs to be right sized (note: there will be a substantial savings in carrying cost for this category, bringing it close to the modified allocation).

Agenda Item #3: Review of the RWPA Portfolio Follow-up: Care Coordination Program

Mr. Spiegler and Ms. Gambone presented an overview of the RWPA Care Coordination Program (CCP) and Medicaid Health Homes (HH).  CCP supports retention in care through home- and community-based patient navigation services, coordinated medical and social services, counseling and coaching in adherence to treatment, directly observed therapy (DOT) for treatment, and health education to build the skills and knowledge needed to maintain stable health.  Clients must be – or become – patients of the clinic with which the program is associated.  Health Home Plus (HH+) is an intensive care management program established to provide HH members the intensive services needed to stabilize their health and social service needs in the community.  HH+ supports PWH by addressing barriers to positive health outcomes, adhering to HIV care and treatment, and achieving viral suppression.  

CCP eligibility is (in addition to general RWPA guidelines) newly diagnosed or out of care, virally unsuppressed, with untreated hep C, pregnant, at high risk of falling out of care, and with demonstrated difficulty managing their own care.  HH eligibility requires three steps, starting with determination of Medicaid eligibility, followed by general HH eligibility (two or more chronic conditions), or a single qualifying condition (HIV, serious mental illness).  The third step is to determine “Appropriateness for HH”: an individual must be assessed and found to have significant behavioral, medical, or social risk factors that require the intensive level of Care Management services provided by the Health Home Program.  Appropriateness is based on a number of determinants of medical, behavioral, and/or social risk, such as Probable risk for adverse events (e.g., death, disability) or lack of or inadequate social/family/housing support.  There are a number of factors to consider when thinking about HH appropriateness.

HH income eligibility requirements (max. $13,590 for a single person household) are much more stringent and lower than RWPA ($67,950).  Many clients in CCP may make above the HH income cut off but still be eligible for enrollment in Care Coordination.  CCP serves as a program for those who may need intensive case management but may not meet the strict appropriateness and/or income eligibility requirements for Medicaid/HH.  Thus, CCP fills gaps not able to be met by Health Homes for patients who do not meet income or appropriateness eligibility.  HH also costs almost twice as much per client per month as CCP ($436 versus $800).  

There was a comparison of service types offered by the two programs.  Many CCP services are analogous to HH services, e.g., intake assessment (called Comprehensive Health Assessment in HH).  Some CCP services are not offered by HH (self-management assessment, directly observed therapy, all group services).  Results from the CHORDS and PROMISE studies of CCP outcomes were reviewed, showing that 88% of CCP clients are engaged in care and 66% virally suppressed (compared to 63% and 49% respectively of those in regular care).  

In a recent meeting with the NYSDOH AIDS Institute Office of Medicaid Policy and Programs, which oversees HH, it was confirmed that documentation of appropriateness for HH is more rigid than documentation of eligibility for CCP.  Both programs target individuals who need support to manage their HIV and other medical conditions, however, individuals with suppressed viral load are generally not appropriate for HH.  Individuals with suppressed viral load are eligible for CCP if they face barriers that make it difficult to maintain VLS or if they meet another eligibility criteria.  Both programs utilize a similar Care Team approach and conduct services at program sites, in the community, and in client home, however, while services in client homes are possible in HH, they are a key, required component of CCP.

Both programs accompany clients to medical and other appointments, however, taking a client to an appointment is possible in HH only if there is a “significant barrier” and only temporarily.  Taking clients to/ meeting clients at appointments and providing advocacy and emotional support before/during/after appointments is a key, required component of CCP.  Services specific to CCP are: Self-Management Assessment; Semi-annual Comprehensive Reassessment; Frequent and ongoing Individual Health Education; Regular Accompaniment to, and advocacy during, appointments; Group Health Education; and Modified Directly Observed Therapy.  

Ms. Gambone reviewed the key takeaways from the CHORDS and PROMISE studies that were presented to PSRA in December showing that CCP clients have significantly higher levels of engagement in care and undetectable viral loads that those in ordinary HIV care programs.

A summary of the ensuing discussion follows:

  • Many CCP service types are provided in other RWPA services (e.g., reengagement in MSV).  There is service coordination within agencies that have multiple programs, in which case the care team decides what staff from which program provides the specific service.
  • There is no way to capture how many CCP clients actually fall into the income gap between Medicaid and RW eligibility.  Data on insurance coverage for CCP clients can be a proxy for income.
  • Health Homes Plus (HH+) are focused on the most high need patients (esp. those with high viral loads), but regular HH have many HIV+ enrollees.
  • HH refers many people who apply but don’t qualify to CCP programs.
  • Cost effectiveness is not a focus for this committee to determine allocations, but the data presented could be misleading as it presents the costs of HH+, but regular HH costs $383 per client per month.
  • Anecdotally, the biggest barriers to care are housing instability and mental health issues.
  • HH enrollees could be missing out on the services that only CCP provides.  Care teams should include providers from both programs for the dually enrolled so that the client can access the full range of services, but the CCP program only bills for those not provided by HH.  During site visits, the context should be provided to CTP/PHS by the program.

Agenda Item #4: Review of the RWPA Portfolio Follow-up: Harm Reduction

Ms. Mackson presented on two aspects of the Harm Reduction Program (HRM): proportion of clients who reported several types of problem substance use, and an analysis of payer of last resort issues.  Definitions of problem substance use (recent use of hard drugs or tobacco, binge drinking, drug use disorder) were provided.  Thirty-nine percent of HRM clients reported hard drug use in the past three months, 61% used tobacco, 24% reported binge drinking, and 42% had moderate to severe drug use disorder.  Seventy-three percent reported a mental health diagnosis in their lifetime, with 67% reporting recent significant mental health symptoms recently.  

The Recipient mapped Medicaid-billable harm reduction services to services provided by HRM agencies and described the number of clients and services, broken down by agencies who are able to bill Medicaid and those who are not.  In order to be eligible to bill Medicaid HRS services, agencies must have a syringe exchange program (SEP) registered with New York State (5 out of 17 total HRM agencies qualify).  Care plans and assessments (i.e., intake and reassessments) were excluded from the analysis.  The analysis was limited to clients who reported being on Medicaid (92% of all HRM clients enrolled and active).  

The Recipient evaluates if the HRM (and all RWPA) contractors are ever able to bill Medicaid for a service type; was the client enrolled in Medicaid on the date of service (includes any retroactive Medicaid coverage); is the service payable by Medicaid for this client; did a staff person eligible to provide Medicaid-payable services deliver the service?  If the answer to any of the previous questionsis “no,” then RWPA is the appropriate payer.  If the service was erroneously reported to RWPA for payment, payment may be recouped.  Following review of service records, contractors should receive a list of services for which payment may be recouped and have the opportunity to justify payment before final determination is made.  

The percentage was given of clients for each service type (e.g., Individual or Group Harm Reduction Counseling, Client Assistance, Health Education, Acupuncture, Overdose Prevention Training, etc.) who were enrolled in HRM programs with syringe exchanges and other HRM programs.  The percentage in HRM programs with syringe exchanges (and thus able to bill Medicaid) ranged from 31% for individual AOD counseling to 43% for group psychoeducation to 10% for group Seeking Safety health education, to 92% for Buprenorphine initial visits.  

A summary of the ensuing discussion follows:

  • The HRM intake form asks about history of mental health diagnosis and if the client is receiving MH care.  Referrals are made if indicated during the service plan development.  This is true for other service categories.    
  • Addressing tobacco use is in the HRM service directive.  Tobacco can be an indicator of self-medication for MH issues.  Also, both HRSA and the NYS AIDS Institute both require that harm reduction programs address it.
  • Medicaid only recently began reimbursing services at SEPs, and HRM programs are 6 years old, thus it was not specified in the procurement that they must be able to bill Medicaid.
  • HRM is in its 6th year and the Integration of Care Committee is working on a new service directive (to be bundled with MSV and Supportive Counseling into one behavioral health directive).  The goal is to complete the directive this planning cycle for procurement in GY 2023.
  • If the Council thinks about requiring future harm reduction service providers to be able to bill Medicaid, they will need to consider the implications for geographic distribution of services.  Also, HRM is a broad category that meets people where they are and provides valuable services that may not fit into a Medicaid billable framework.  Medicaid has many caveats on reimbursement for harm reduction and rules are still evolving.

Agenda Item #5: GY 2022 Tri-County Spending Plan

Mr. Klotz explained that at the March PSRA meeting, PSRA will consider a spending scenario plan for GY 2022 that anticipates a reduction in the grant award.  There will be considerable savings in the carrying cost of programs due to permanent contract take-downs and terminations.  There will also be some new allocations to fund the first six months of oral health programs and a full year of funding the Psychosocial Support Services for TIGNBNC.  A reduction in the award can be covered by reducing the ADAP allocation, which can be restored completely (and beyond) through reprogramming and carryover (underspending in GY 2021 is expected to be larger than usual again).  PSRA will then use the rest of the planning year to synthesize the vast amount of data reviewed over the last year to make adjustments to the allocations for the GY 2023 application spending plan.

Mr. Klotz presented the GY 2022 Spending Scenario for the Tri-County region, approved by the Tri-County Steering Committee (TCSC) in December.  For several years, the TCSC has requested level funding, given that there are fewer local resources in the TC region (e.g., no HASA).  The Committee is recommending this strategy again for GY 2022.  The Committee understands that the Tri-County region’s percentage of program dollars has grown while the proportion of the EMA’s PWH who live in region has decreased.  The Committee also understands that NYC programs have been reduced over the years to absorb cuts to the award, mostly by taking the funds from the ADAP allocation, which is partially restored through reprogramming and carry-over.   Over the next year the Committee will conduct planning for 2023 and will use a similar methodology as the PSRA Committee used this year for NYC programs, using service category data on client enrollment, spending rates, priority populations and payer of last resort considerations to readjust Tri-County allocations.  It was also noted that the bulk of the Emergency Financial Assistance category is for use in the NYC portion of the EMA.

A motion was made and seconded to approve the GY 2022 Tri-County Spending Plan as presented.  The motion was adopted 12Y-0N.  

The Recipient staff were thanked for the huge amount of work they’ve done to provide PSRA with data for planning.

There being no further business, the meeting was adjourned.