Priority Setting & Resource Allocation Committee Minutes June 13, 2022

Meeting of the Priority Setting & Resource Allocation Committee

Monday, June 13, 2022

By Zoom Videoconference

2:35 – 5:10

Members Present: Marya Gilborn (Co-chair), Jeff Natt (Co-chair), Fulvia Alvelo, Matt Baney, Broni Cockrell, Billy Fields, Joan Edwards, Graham Harriman, Guadalupe Dominguez Plummer, Claire Simon, Terry Troia, Victor Velazquez, Dorella Walters

Members Absent: Paul Carr, Eunice Casey, Matthew Lesieur, Henry Nguyen, Leo Ruiz

Other Council Members Present: Charmaine Graham

Staff Present: David Klotz, Melanie Lawrence, Scott Spiegler, Johanna Acosta, PhD, Gina Gambone, Deborah Noble, Giovanna Navoa, Frances Silva, Arnelle Vincent, Ilana Newman, Nadine Alexander, Kimbirly Mack, Patrick Chan (NYC DOHMH); Gemma Barclay, Rosemarie Santos, 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 May 9, 2022 meeting were approved with no changes.  There was a reminder of the conflicts of interest rules.

Agenda Item #2: GY 2022 Final Spending Plan

Mr. Klotz explained that for the first time in nine years, the EMA received an increase in the Ryan White Part A (RWPA) grant award.  The bulk of the increase was in Base supplemental funds, which is based on the application score.  The application is a three-year application, which means the score remains the same for GY 2023 and 2024.  There was also an increase in formula funds, which are based on the number of PWH reported to the CDC.  This was the area where most of the reductions have been, which means that other EMAs’ HIV incidence is coming more into line with NY.  HRSA announced that every EMA got an increase due to the $10M additional appropriated by Congress plus $20M available from the pool of carryover available due to the waiver of penalties on underspending.  The waiver is in effect again for GY 2021, which means that the award will likely remain stable for at least another year.  

The amount of funds to be allocated includes both the increase in the award, as well as uncommitted funds from savings in carrying costs of programs from GY 2021.  That amount is slightly offset by the allocations that PSRA already agreed to ($250K for the first 6 months of new oral health programs, and $443,500 to fund a full year of PSS TIGNBNC).  This leaves a total of $3.8M in uncommitted funds to allocate.

Ms. Plummer presented a plan developed by Council and Recipient staff to allocate the additional funds.  All enhancements are permanent and on-going.  The following are the proposed enhancements:

1. Housing (HOU): $837,136 to address the rise in rent and operations.  Of the total, $515,065 will NYC Short-term Housing, $176,573 to NYC Rental Assistance, $125,276 to NYC Housing Placement Assistance, and $20,222 for Tri-County Short-term Housing.
2. Food & Nutrition Services (FNS): $355,801 for NYC programs, $59,975 for TC to provide permanent enhancements to food services.
3. Emergency Financial Assistance (EFA): $850,000 to serve the entire EMA.  This program, originally based in TC, has done a phenomenal job extending services to NYC.  The program is currently dramatically overperforming and can benefit from additional funds to cover the increase in demand.  The program spent over $140,000 in March 2022 alone and needs to hire a full-time staff to manage the increase in number of clients requesting EFA services.  The Recipient is also requesting that the Council make permanent the per client annual cap of $5,000 (originally $2000).
4. Oral Health Services (OH): The original spending scenario called for funding two programs (to start mid-year) at an annualized allocation of $250,000 each.  There is a third fundable proposal, and programs’ maximum reimbursable amount (MRA) can be increased to $300,000 each.  Thus, an additional $200,000 above what was already pledged is required to fund three programs for 6 months.
5. ADAP: The balance of the uncommitted funds ($1,508,065) would go to ADAP, with the understanding that about $1.3M will be taken back in GY 2023 to fund the new Ambulatory Outpatient Services for Older PWH.

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:

1. FNS: $120,000 to provide additional food vouchers and pantry bags.
2. 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.
3. 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.
4. 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 11^th 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 9^th 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.