Priority Setting & Resource Allocation Committee Minutes March 11, 2019

PRIORITY SETTING & RESOURCE ALLOCATION COMMITTEE

Cicatelli Associates, 505 Eighth Ave., NYC
Monday, March 11, 2019, 3:10 – 5:00pm
MINUTES

Members Present: Jan Hudis (Co-chair), Matthew Baney (Co-chair), Randall Bruce, Broni Cockrell,

Paul Carr, Amber Casey (for Graham Harriman), Billy Fields, Jesus Maldonado, L. Freddy Molano, M.D., Jan Carl Park, Carmelo Cruz Reyes (by phone), Claire Simon (by phone), Barry Zingman, MD (by phone)

Other Council Members Present: Tim Frasca, John Schoepp 

Members Absent: Joan Edwards, Steve Hemraj, Matthew Lesieur, Oscar Lopez, Jeff Natt, Saul Reyes

Staff Present: David Klotz, Scott Spiegler, Karen Miller (NYC DOHMH); Bettina Carroll, Gucci Kaloo (Public Health Solutions)

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

Mr. Spiegler presented the first four 2019 Service Category Fact Sheets.  The Fact Sheets include a service category overview, data on historical performance (spending compared to the original allocation), payer of last resort (POLR) issues, data on service utilization and service type, and systems-level considerations.  The back page data on service units and the spark lines from the previous version of the Fact Sheets have been deleted, as per the PSRA consensus that the data was not useful.  General comments about the fact sheets include: 

• The word “rank” when listing most frequently used service types mischaracterizes them as if they are by level of importance.  Another word (e.g., “frequency”) should be substituted. The format for all fact sheets should be uniform.
• The POLR section should (like the revised POLR Tool) be narrowed to the federal definition, focused on federal payers like Medicaid and Medicare. 

Below is a summary of each Fact Sheets followed by a summary of the ensuing discussion.

1. Food & Nutrition (FNS): This category includes: (1) Food services, including home-delivered meals, congregate meals, pantry bag services, and food vouchers; and (2) nutritional services, including Individual and group nutritional counseling and provision of nutritional supplements.  Historically, this service category over-performs with an average over performance of 104.5% (2-year average).  Due to the category’s over-performance, in FY2018 contracts were enhanced by 1.8M to enhance service delivery.  Early last year, the President proposed changes to SNAP’s (food stamps) provisions including changes to its categorical eligibility.  On January 4, 2019 the Trump administration released a document addressing the proposed change stating that it would limit broad-based categorical eligibility to households that receive cash TANF (Temporary Assistance to Needy Families) or other substantial assistance from TANF.  This proposed policy change will impact states including NY that have opted for broad-based categorical eligibility as states would have to redefine their TANF eligibility requirement.  The government’s three-week shutdown greatly impacted the program including staff cuts and the availability of WIC (Women, Infants, and Children Program) services.  Support for this program is subject to available funding and the availability of food. If there is no resolution made by Congress and the president, funding is expected to run out by February 2019.  

1. summary of the discussion on the FNS Fact Sheet follows:

• All clients must have treatment plans, thus this is the service type with the most clients.  The service types with the most number of units are pantry bags and home-delivered meals (over a quarter million each).
  • When reading the spending graphs, one must pay attention to the numbers of the Y-axis to not get the impression that over- or under-performance is out of proportion.
  • The enhancement to the FNS allocation in the current year allowed for increased rates to improve quality of food and services, but did not add additional capacity.  Also, it was done late in the year due to the late receipt of the grant award. 
  • There needs to be additional ways to measure success, not just spending and number of clients. 

There is information on health outcomes (esp. re-engagement in care, viral load suppression). 

The program is not able to solve the underlying issues behind food insecurity (poverty, etc.).

• The new FNS directive focuses on individualized dietary goals (e.g., medically tailored and culturally appropriate foods), which will be more expensive than the current model.  PSRA will have to consider this when looking at the allocation for this category. 
  • CHAIN data can help provide information on unmet need.  There is also a paper that was published on Food Insecurity and HIV health outcomes that will be distributed.

1. Medical Case Management/Transitional Care Coordination (TCC): TCC provides stabilizing case management for homeless and unstably housed individuals.  IOC is currently reviewing this service model.  TCC spending performance has been excellent over the past 4 years with a vast over-performance across the board.  2011 was the last year the category underspent.  TCC over-performed every year since, between 109%-138%.  Spending plans were modified by the PC to account for over-spending across the portfolio.  The NYS Office for People with Development Disabilities offers comprehensive case management and service coordination for those eligible.  The ACA created an optional Medicaid State Plan benefit so states could establish Health Homes.  In NYS, Health Homes coordinate care for persons who have chronic conditions.  This integrates coordination for primary, acute, behavioral health and longterm services intended to treat the whole person.  Eligibility requirements for MCM programs are specifically HIV treatment adherence related which is not the case for Health Homes. 

1. summary of the discussion on the TCC Fact Sheet follows:

• This is an intensive, short-term intervention meant to move someone into longer-term case management, but many client like their case manager and want to stay and do not graduate, changing the service into a regular case management model.
  • The Integration of Care Committee (IOC) is reviewing this model and may roll it into another service category (e.g., Housing). 
  • The service targets the homeless but is not a housing service.  Moving it into the Housing category will eliminate the referrals that current providers have to make.  
  • It is important to keep the outreach component (as new Care Coordination programs can be reimbursed for). 
  • PSRA should put aside reconsidering the allocation for this category while IOC develops its recommendation for a new service model.  It will likely not be rebid until late 2020 at the earliest. 

1. Mental Health (MHS): This service category provides comprehensive mental health programs in health centers and community-based organizations that are certified to deliver outpatient mental health services and are co-located with HIV primary care services or have established linkages with HIV primary care providers. Services may also be provided in the home, as necessary to meet a client’s needs.  While Mental Health has historically underspent, spending performance has consistently fluctuated, exceeding 100% of the overall allocation in 2016.  As part of the NYS Medicaid Redesign, behavioral health services have been integrated into Medicaid Managed Care Plans eligible adults are able to receive physical and behavioral health benefits through managed care.  Adults enrolled in Medicaid and 21 years or older with select Serious Mental Illness (SMI) and substance use disorder (SUD) diagnosis having serious behavioral health issues are eligible to enroll in Health and Recovery Plans (HARP).  Individuals enrolled in an HIV Special Needs Plan (SNP) are eligible to dually enroll in HARP and receive enhanced benefits of HARP.  RWPA MH Service delivery began in June 2016, therefore, service utilization data for 2016 will not account for the full year.  Reported units of service are not de-duplicated, so some instances of a client receiving the same service more than once per day may exist.  NYC DOHMH offers outpatient and psychiatric services as part of their Community Health Centers regardless of ability to pay or immigration status. NYC HHC offers emergency psychiatric services, treatment for mental illness and support for 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 mental health programs is to be Article 28 or 31 certified so they can bill allowable services to Medicaid.

1. summary of the discussion on the MHS Fact Sheet follows:

• There is a big MH initiative in NYC, and Medicaid expansion is going to cover services that are an exact match for what RWPA pays for.  RWPA can be used for wrap-around services (e.g., navigation) and to pay for services above the Medicaid cap (e.g., extra counseling sessions).  
  • Requiring all RWPA MHS providers to become Medicaid reimbursable has increased the capacity of the Medicaid system to serve the specific needs of PLWH and RWPA clients. 
  • There is a big administrative burden in enforcing POLR requirements.  
  • Psychiatric screening is usually paid for by Medicaid and is expensive, as it requires an MD on staff.
  • The utilization of MH counseling is still high (group counseling is usually not Medicaid reimbursable).  
  • Individual counseling is required for all clients, even if they are also in group therapy. 
  • The overall number of RWPA clients is low considering the need.  This is partially due to the number of PLWH who are Medicaid eligible for these services, which require a DSM diagnosis (those without a DMS diagnosis are generally served through Supportive Counseling Services).  New models should be considered by the Council, committees and Grantee to improve the number of clients receiving mental health care engagement, assistance and reengagement services. (DOHMH is providing technical assistance to improve outreach and enrollment.)
  • MHS providers have under-performed even after the category was rebid.  The one year that the Fact Sheet shows over-spending is due to the overlapping of cast- and performance-based contracts during the rebid. 

VI. Supportive Counseling (SCI): Supportive Counseling provides supportive counseling specifically targeted to those individuals whose need for mental health services does not result in a DSM-V diagnosis and thus would not be eligible for licensed mental health services that are reimbursable by Medicaid. Contracts were last rebid in 2014.  In 2013, SCI overspent by 123%; however they were capped at 103% due to available funds for reprogramming at closeout.  Following years, 2011 – 2014, SCF was capped at approximately 15% as per the Planning Council Reprogramming Plan.  Between 2016 and 2017, SCI overspent by 109.6% and 116.4%, respectively.  No large, federal payer for this category. The NYC Administration for Children’s Services offer programs in family home care, child care, head start/early start, transitional child care and family services for domestic violence counselling, mediation, anger management and crisis intervention.  Target population-specific services are offered by the NYS AIDS Institute and NYS OTDA for HIV-infected women and their families and clients who are unstably housed, respectively.  The category supports family-focused services that strengthen and support children of HIV+ parents and other family members.  The licensed mental health services offered in this category are not Medicaid billable due to the absence of a DSM-V diagnosis. The counseling services offered aim to ameliorate the barriers to access, reduce stigma (for the client and family) and facilitate continued engagement in medical care to improve physical and mental health outcomes. 

A summary of the discussion on the SCI Fact Sheet follows:

• There is more latitude in SCI than MHS to serve people, including those not engaged in care. 
• MH providers tend to only enroll people who come to them and not do outreach.
• NY State programs also differentiate between those who enroll and those who complete and graduate out of the program.

Additional Service Category Fact Sheets will be presented in April.  Mr. Klotz will prepare a narrative summary of the Scorecards, Fact Sheets and POLR Tool by service category.  The sub-committee that will consider a hybrid document that combines data from the Scorecards and Fact Sheets will convene next month. 

There being no further business, the meeting was adjourned.