Meeting of the Priority Setting & Resource Allocation Committee
Monday, July 11, 2022
By Zoom Videoconference
3:05 – 4:30
Members Present: Marya Gilborn (Co-chair), Jeff Natt (Co-chair), Fulvia Alvelo, Matt Baney, Paul Carr, Broni Cockrell, Billy Fields, Graham Harriman, Matthew Lesieur, Henry Nguyen, Guadalupe Dominguez Plummer, Claire Simon, Terry Troia, Dorella Walters
Members Absent: Eunice Casey, Joan Edwards, Leo Ruiz, Victor Velazquez
Staff Present: David Klotz, Melanie Lawrence, Johanna Acosta, PhD, Ilana Newman, Nadine Alexander, Kimbirly Mack, Daniel Bickram, Karen Miller, Renee James, Adriana Eppinger-Meiering (NYC DOHMH); Gemma Ashby-Barclay, Rosemarie Santos, Arya Shahi (Public Health Solutions); J. Kerwin (NYSDOH AIDS Institute)
Agenda Item #1: Welcome/Introductions/Minutes
Ms. Gilborn and Mr. Natt opened the meeting, followed by a roll call and a moment of silence. Two new DOHMH staff were introduced: Mr. Bickram, Office Manager for the Planning Council, and Ms. Eppinger-Meiering, Program Planner in the Care & Treatment Program. The minutes of the June 13, 2022 meeting were approved with no changes. There was a reminder of the conflicts of interest rules.
Agenda Item #2: Priority Ranking Score: Ambulatory Outpatient Services for Older PWH
Mr. Klotz explained that the PSRA needs to assign a priority ranking score for the new Ambulatory Outpatient Care for Older PWH (AOS) service category that will be funded in GY 2023. HRSA requires that all service categories be ranked in priority order. PSRA has used a ranking tool developed over 15 years ago that uses four criteria: payer of last resort, access to/maintenance in HIV-related medical care, consumer priority, and fills specific gaps/needs. The scoring scale for each criterion was explained. Ranking scores are not linked to allocations except when applying across-the-board increases or decreases throughout the portfolio, in which case higher ranked categories get proportionately lower decreases or higher increases. The AOS allocation was agreed upon by PSRA when the Recipient presented a cost analysis in June.
Mr. Harriman presented the details of the AOS category’s service model, including leveraged care coordination, expanding provider capacity to pay for extended visits, screenings and assessments for age-related physical and behavioral co-morbidities, nurse case management, and referrals. Training for providers is also part of the model.
Payer of Last Resort (POLR)
Mr. Kerwin lauded the Council for the innovative AOS service model and for addressing gaps in coverage and the lack of provider capacity to adequately address the health needs of aging PWH. There was discussion about whether the POLR score merits an 8 or a lower number. While the service system needs to innovate to meet evolving needs, almost all PWH over 50 are in care (even if it’s not optimal), and this age group has the highest rates of viral suppression. Medicaid, Medicare, ADAP and private insurance pay for these services and the AOS category is an “add on”. There are some populations that are not eligible for government insurance (e.g., undocumented), but that’s true for all Ryan White services. Medicaid and other programs pay for a medical encounter, but AOS will enable longer visits and provide ancillary services.
The final consensus was to score AOS 8 for POLR.
Access to/Maintenance in Care
This criterion measures whether a service meets the HRSA goal for all Ryan White services to link people to HIV medical care and maintain them in care. The clients that will use AOS are already in HIV-related medical care. The service will provide added value, ancillary services and specialty care.
There was a consensus to score AOS 5 for Access/Maintenance.
Consumer Priority
It was noted that AOS was the first service directive developed by the Consumers Committee, to address a well-documented need that was often identified by PWH in the community.
There was a consensus to score AOS 8 for Consumer Priority.
Specific Gaps/Needs
There was agreement that AOS perfectly fit this criterion, as it is expressly intended to fill a specific service gap and an emerging need.
There was a consensus to score AOS 8 for Gaps/Needs.
Agenda Item #3: GY 2023 Application Spending Plan
Mr. Klotz explained that the EMA is required to submit a spending request in the GY 2023 grant application. The EMA can request up to 5% above the current year’s award and we traditionally ask for the maximum as a statement of need. In the fall/winter PSRA will conduct scenario planning for a possible decrease in the award.
The MAI award is fully formula-driven, and as in past years, the draft request for the application is identical to this year’s award. For the FY 2022 application, the Tri-County Steering Committee is requesting a 5% proportional across-the-board increase based on service category ranking scores to address inflation. The NYC Base award needs to allocate $1,333,800 to AOS based on the cost analysis presented to PSRA. $450,000 is also needed to pay for a full year of Oral Health Services, which begin on Sept. 1, 2022. Asking for these as part of an increase request will be easily justifiable in the application. In the case of flat funding or a decrease in the award, PSRA had already agreed when approving the final GY 2022 spending plan that funds for these initiatives will come from the ADAP allocation. PSRA will need to decide for the application spending plan how to allocate the remaining $1,690,828 from the 5% increase request. It was noted that during discussions in the Executive Committee and Planning Council on the final GY 2022 spending plan, it was noted that the need for funds to address staff retention and the higher cost of doing business due to inflation is faced by providers across the portfolio, not just in categories that received targeted increases (Housing, Food & Nutrition).
A motion was made, seconded and approved 12Y-0N to adopt the GY NYC Base 2023 application spending plan as presented with a proportionate increase to all categories except ADAP, Housing, FNS, AOS and Oral Health.
The Committee thanked retiring members Mr. Carr and Ms. Cockrell. Ms. Gilborn and Mr. Natt were thanked for their leadership and the committee and staff thanked for their dedication and hard work.
There being no further business, the meeting was adjourned.
Mr. Klotz noted that a small amount of ADAP funds was moved from MAI to Base so that the allocations exactly match the respective award amounts.
A summary of the discussion follows:
- Part of the HOU funding will be for staff retention initiatives to address ongoing COVID-related burnout and loss of staff, particularly in congregate facilities. Short-term rental programs will need more staff to serve additional clients.
- The NYC housing stock is dropping, leading to even higher rents. The enhancement will cover expenses for leases in existing programs. Paying for ongoing increases needs to be done gradually so it can be sustained over time.
- Clients already receive financial education and planning services to help them manage their living expenses.
- The increase in FNS rates matches the rate of inflation and is applicable across all service types (home-delivered, congregate, pantry, vouchers). Programs can either expand capacity if they are able, but the intent is to allow them to sustain their current levels of service.
- The programs are reverting to fee-for-service (i.e., performance-based) reimbursement, which means that overperforming programs will be able to accept reprogramming funds during the year.
- The standard amount of a voucher has been increased to $70, up from $50 (an amount based on costs when the programs were rebid in 2019). The number of vouchers a client receives is determined by that client’s needs as worked out with the program.
- Only some FNS providers have a voucher program, and it would be too difficult to set one up mid-year.
- Some areas (e.g., Staten Island) have food deserts and the program will give vouchers for a specific supermarket, provide transportation and bring clients in for ancillary services.
A motion was made, seconded and approved 12Y-0N to adopt the final GY 2022 spending plan as presented.
Agenda Item #3: GY 2021 Carryover Plan
Ms. Plummer reported that the carryover from previous year is unusually high for the second year in a row. A detailed accounting of the GY 2021 fourth quarter commitment and expenditure report will be given to the Executive Committee on Thursday. HRSA issued a waiver again from any penalties for carrying over more than 5% of the award. The past two grant years were unpreceded due to the COVID-19 pandemic and under normal circumstances we would not be managing such a large carryover amount. The final carryover from GY 2021 available to allocate in GY 2022 is $7,627,207. This is largely attributed to the cost-based reimbursement structure across the RWPA portfolio implemented in the past two years due to the pandemic. Also, most RWPA funded organizations faced staff turnovers with some staff leaving due to burnout and for higher paying jobs offering telework/full remote work. This great resignation has also been experienced at DOHMH for staff supported on the RWPA budget, and the city is moving very slowly on job postings and start dates for new hires.
The HRSA rules for use of carryover funds were explained (one-time program funds that typically arrive late in the grant year and must be fully spent by February 28, 2023). The proposed uses of the funds (all for both NYC and TC) are:
- FNS: $120,000 to provide additional food vouchers and pantry bags.
- Value-based payments for Medical Case Management (VBP): $1,200,000. This was implemented successfully in GY 2021 using GY 2020 carryover. Payments are made on four measures using benchmarks for enrolling virally unsuppressed clients, case conferencing, health education sessions, and achieving VLS. Ms. Gambone explained the details.
- Culturally and Linguistically Appropriate Services (CLAS) Standards: $2,106,000 to allow every sub-recipient (RWPA provider) to complete a federally-mandated CLAS Standards assessment tool and work plan, as outlined in the Council’s Framing Directive. This will help improve quality of services, address inequities, and reach PWH who may need translation and interpretation services at $26,000 per provider across a total of 81 unique agencies.
- ADAP: The remaining $4,201,207 would be absorbed by ADAP, which has taken severe reductions every year to absorb cuts to the award and pay for new initiatives. ADAP Director Julie Vara has affirmed that they are able to absorb and spend the additional funds.
A summary of the discussion follows:
- The amount is based on the number of providers that offer those service types, agency spending trends and capacity.
- There were challenges implementing the phone/telehealth services in the previous year’s carryover plan. HRSA’s scrutiny of this item raised red flags and held up final approval of the plan. There are strict federal guidelines around the use of funds for that purpose.
- More creativity should be considered for increasing the amount for FNS, such as temporarily increasing the amount of each voucher, or eliminating the cap on vouchers per client per week. [It was reiterated that the number of clients is based on client needs.]
- There are concerns that the FNS providers cannot absorb more than what’s proposed, partially due to staff capacity limits.
- Many agencies already use gift cards, but there are strict documentation requirements for cards that can be used in stores that sell unallowable goods.
- Agencies should collaborate to extend services further.
- The Recipient can spend more if they alert the programs early enough to prepare for when the funds finally become available.
- Shortly before the end of the grant year, the Recipient starts to roll up unspent carryover funds and reallocate them to ADAP so that they can be fully spent before the end of the year.
- It would be useful to capture measurements for VBP for people at six months to assess if they are making progress toward VLS.
A motion was made, seconded and approved 10Y-0N to adopt the GY 2021 carryover plan as presented with the change of the amount for FNS to $1,000,000 and the reduction of the ADAP amount to $3,321,207.
Mr. Klotz explained that there will be two major items on the July 11th meeting agenda: developing a ranking score for Ambulatory Outpatient Services, and approving a spending plan for the application with a request for a 5% increase.
There being no further business, the meeting was adjourned.
It is difficult to project utilization, which is why it’s best to start with what is doable and assess utilization for the future.
Reduction Planning: Medical Case Management
Ms. Plummer presented the Recipient’s perspective on the possibility of reducing the MCM allocation. She gave a brief overview of the category and the services it provides, as well as current funding level and number of programs and enrolled clients. PSRA has been considering reducing the allocation in order to fund AOS, Oral Health and absorb cuts to the award based on payor of last resort (POLR) issues, specifically duplication of services provided by Medicaid Health Homes (HH). At this time, the Recipient is strongly opposing the Council’s consideration to reduce MCM, asking the PSRA to hold off on a reduction to this service category until POLR site visits are conducted so that the reduction scenario is data-driven and well-informed. The Recipient is scheduled to conduct these site visits starting next month with results presented to PSRA by next cycle in January.
The Recipient believes that MCM fills gaps not met by HH (clients who are not Medicaid eligible or do not meet the more stringent HH eligibility or appropriateness criteria). MCM is the most rigorously evaluated program in the NY EMA, with studies (funded by NIH) showing effectiveness for identified priority populations, including those who are virally unsuppressed, out of care for over a year or more, and those not on medication for over a year or more. The MSM program is the only service category in the entire RWPA portfolio which has been defined by CDC has an evidence-based intervention appearing in the CDC’s Compendium of Evidence-Based Interventions and Best Practices. There are no available data showing the effectiveness of Health Homes, and MCM costs 45% less per client.
Interviews with MCM program directors pointed out other differences between MCM compared to HH: smaller caseloads, a good working relationship with medical staff at specific clinics, specific HIV care with stigma and confidentiality awareness, adaptable models to fit client needs. Representatives from two MCM programs (Mount Sinai and Argus Community Services) testified to the effectiveness of their programs, focusing on effective partnerships, referrals, the ability to provide directly observed therapy and home visits, and client outcomes (esp. VLS). A client at the Argus program testified to the importance of the program to her physical and emotional health. She added that she had previously been enrolled in HH and found it much less helpful. The providers also noted that the number of dually enrolled clients is very small (about 3% at Argus). Cases can be closed and transferred to HH if that program better fits the client’s need.
Ms. Plummer described the POLR monitoring at MCM programs. She reiterated that the Recipient is asking PSRA to hold off on any reductions to MCM until the data from the POLR site visits is available (by January 2023). The decision in the PSRA committee on source of funding will be pending of the Payor of Last Resort site visits. Source of funding could include reductions to the ADAP or Care Coordination (aka MCM) allocations or other sources.
Noting that no one in PSRA has doubted the effectiveness of MCM, and the allocation decision would be based on POLR issues, Mr. Klotz explained that PSRA needs to develop two spending plans for 2023. The first is the application spending plan due by then end of July, which typically request the maximum increase allowed by HRSA (5% over the current year’s award) to demonstrate the need in the EMA. The second plan is the actual plan, developed over the fall and winter (known as the scenario plan) that plans for the actual award, which is likely to be another reduction (the 9th year in a row). There was a consensus to make any decisions on reductions during the scenario planning process.
There being no further business, the meeting was adjourned.
