Meeting of the Priority Setting & Resource Allocation Committee
Monday, February 6, 2023
By Zoom Videoconference
3:05 – 4:00
Members Present: Marya Gilborn (Co-chair), Jeff Natt (Co-chair), Fulvia Alvelo, Matt Baney, Kyron Banks, Joan Edwards, Billy Fields, Graham Harriman, Guadalupe Dominguez Plummer, John Schoepp, Dorella Walters
Members Absent: Steve Hemraj, Matthew Lesieur, Henry Nguyen, Claire Simon, Terry Troia
Staff Present: David Klotz, Scott Spiegler, Johanna Acosta, PhD, Scarlett Macias, Doienne Saab, Mary Irvine, Faisal Abdelqader, Nadine Alexander, Tye Seabrook, Karen Miller, Deb Noble, Roland Torres, Ilana Newman, Adrianna Eppinger-Meiering, Grace Herndon, Patrick Chan (NYC DOHMH); Arya Shahi, Gemma Barclay (Public Health Solutions)
Guests Present: Dan Lowy, Maria Rodriguez (Argus Community); Diane Tider (Mt. Sinai); Andrea Ruggiero, Karen Mandel (Open Door Health Center)
Agenda Item #1: Welcome/Introductions/Minutes
Ms. Gilborn and Mr. Natt opened the meeting, followed by a roll call and a moment of silence. The minutes of the January 9, 2023 meeting were approved with no changes.
Agenda Item #2: Medical Case Management (MCM) Payor of Last Resort Site Visit Report
Mr. Klotz explained that, as a follow up to last year’s presentation comparing RWPA MCM/Care Coordination programs to Medicaid Health Homes, the Recipient was asked for data on payer of last resort site visits to those programs, which ensure that programs are not duplicating services or enrolling clients who can receive the same service through a different payer.
Ms. Plummer, Mr. Shahi and Mr. Abdelqader presented the data from the POLR site visits. As background the MCM program supports retention in care through coordination of medical and social services, accompaniment, counseling, directly observed therapy (DOT) and health education. Funded at $21.1M in NYC with 24 programs, it served 3830 clients in GY 2021-22. The comparison with Health Homes was revisited (MCM can enroll clients who do not qualify for Medicaid, Health Homes have “appropriateness criteria”, etc.). MCM has also demonstrated its effectiveness through the CHORDS and PROMISE studies (presented previously) and costs 45.5% less per client. MCM programs also have smaller caseloads, are tied to a specific medical clinic and have HIV-specific care.
All 24 providers received a POLR site visit between July and October 2022. At the site visit, Public Health Solutions staff requests documentation, asks for answers to contractual questions (e.g., policies and procedures, dual enrollment statistics, etc.), and looks at client insurance status (particularly for Medicaid). The site visits looked at a sample of clients who received the various service types offered by the programs (care plan development, coordination with providers, case conference, accompaniment, etc.). They found that no recoupment was needed. Recoupment is when programs were found to have paid for a service for which the client was eligible in another program for which they are enrolled and the payment is taken back. In addition, all programs were found to screen for dual enrollment at intake, and most at reassessment too.
Thirteen providers had existing written policies in place and the remainder were given recommendations to have them in place by the end of the grant year (2/28/23). Site visits checked for dual MCM/Health Homes enrollment. Duplication of services for dually enrolled clients is only possible if the agency’s CCR/MCT program and Health Home program do not operate distinctly from each other. Nine MCM providers have an internal HH program, only two of which allow for dual enrollment.
In response to a data request from the Committee submitted by Council staff, the Recipient reported that of MCM clients in GY 2021, 21% were not virally suppressed at intake, and 79% are. The numbers were similar for those not on Medicaid and those who are. Of 23 MCM programs reviewed, 5 have Part B case management funding, and 9 have Part C funding.
Representatives from two MCM providers, Argus Community (Bronx) and Mt. Sinai (Manhattan) reported on how they manage POLR. At Argus, new referrals are screened for Health Home status at intake. Program staff discuss the two programs and their services at intake and every 6 months. If an MCM client chooses to enroll in a Health Home after becoming virally suppressed and their medical care has stabilized, they are referred for Health Home services and the case is closed. For dually enrolled clients, they work in conjunction with the Health Home care manager so as to not provide the same services until the client is virally suppressed and stable. Some clients find dual enrollment confusing and they choose to work with just one program at a time. Dual enrollment will be discontinued next fiscal year due to administrative burden of tracking clients across both programs. All discussions with the client regarding the HH program is documented in a progress note.
At Mt. Sinai, staff are clear on the eligibility criteria, which is a quality indicator. Sometimes clients who are undetectable are enrolled who have other significant needs, e.g. an upcoming transplant, a pregnancy, cancer, HCV treatment. The main criteria is a detectable viral load, addressed with frequent Health Education and DOT, where accepted. Client testimonials from both programs were relayed.
In response to questions from Mr. Harriman and Mr. Natt, it was explained that samples for chart reviews were based on services already provided, paid for and reported to eSHARE. The site visits and POLR policies also account for similar services provided by Ryan White Parts B and C, in addition to Health Homes.
Mr. Harriman thanked the Recipient for the thorough presentation, which answered the questions that the PSRA had concerning the MCM program.
Agenda Item #3: GY 2023 Spending Scenario
Mr. Klotz reviewed the GY 2023 Spending Scenario Plan approved by the Committee in January. The methodology will be implemented when the EMA received its full notice of award. There will be up to a $2M targeted reduction to ADAP, and if there is still a deficit, there will be a proportionate across-the-board reduction to other categories weighted by ranking score. The need to fully fund Oral Health Services and to fund the new Outpatient Ambulatory Services for Aging PWH means that in a flat funding scenario, there would be a deficit of almost $1.8M. The Tri-County Steering Committee has approved a spending plan with a reduction of $233,000. The upfront reduction to ADAP would cover the entire deficit up to a reduction in the award of $450,000.
Mr. Shahi explained that there will be no savings in the carrying costs of programs from GY 2022 into GY 2023. Contracts were cost-based for two years due to the COVID-19 pandemic, and no analysis of chronic underspending was possible for this year. Also, there were no contract terminations or other permanent takedowns. Programs have returned to hybrid performance-based and cost-based reimbursement and an analysis will be possible for savings in GY 2024.
Mr. Klotz presented the Tri-County GY 2023 Spending Plan. After reviewing Service Category Fact Sheets over the last few months, the Committee voted to reduce its largest category, Medical Case Management, by $117,000 and to reduce the remainder of the portfolio by $116,000 through an across-the-board weighted reduction. The region still receives a larger proportion of overall program funds than their proportion of PWH in the EMA.
A motion was made, seconded and approved 9Y-0N to accept the Tri-County GY 2023 Spending Plan as presented.
The next PSRA meeting will be on Monday, April 10th.
There being no further business, the meeting was adjourned.