Priority Setting & Resource Allocation Committee Minutes May 11, 2020

Meeting of the
PRIORITY SETTING & RESOURCE ALLOCATION COMMITTEE
Monday, May 110, 2019
By WebEx Videoconference 3:05 – 5:00pm
MINUTES

Members Present: Jeff Natt (Co-chair), Dorella Walters (Co-chair), Paul Carr, Broni Cockrell, Graham Harriman, David Klotz, Matthew Lesieur, Oscar Lopez, Jesus Maldonado, Carmelo Cruz Reyes, Michael Rifkin, Leo Ruiz, John Schoepp, Claire Simon, Terry Troia, Rob Walker

Members Absent: Randall Bruce, Joan Edwards, Steve Hemraj, Barry Zingman, MD

Other Planning Council Members Present: Lisa Best, Marcy Thompson

Staff Present: Clare Biging, Melanie Lawrence, Kimbirly Mack, Guadalupe Dominguez Plummer, Dalveer Panesar, Faisal Abdelqader, Johanna Acosta, Eleanora Jimenez-Levi, Dave Ferdinand; (NYC DOHMH); Bettina Carroll, Gucci Kaloo (Public Health Solutions)

Agenda Item #1: Welcome/Introductions/Minutes

Mr. Natt and Ms. Walters opened the meeting, followed by a roll call and a moment of silence.  The minutes of the April 20, 2020 meeting were approved with no changes.

Agenda Item #2: Follow-up: Non-Medical Case Management (NMG)

Mr. Harriman gave a recap of the NMG data presented at the March meeting was provided, including the service category’s HRSA definition and program guidance, NY EMA program specifics, and areas of overlap with other Ryan White Part A (RWPA) programs.  Ms. Biging presented follow-up data that was requested by PSRA.  A breakdown of NMG clients’ insurance status by age was provided.  Seventy-three percent of all NMG clients are enrolled in either Medicaid or Medicare, and 22% are uninsured.  Clients with ‘No Insurance’are not able to be counted in any other insurance status.  Clients may have Medicare and Medicaid, but are only counted once in the table.  Insurance status is categorized as unknown for any clients for whom the type of health insurance is not available.  The total number of de-duplicated clients in NMG for 2019 is 561.

Of the uninsured clients, many were dually enrolled in other RWPA services, especially legal services, followed by Harm Reduction.  Dual enrollment is when a client is enrolled and has had at least one service in NMG for 2019 while also being enrolled and having had at least one service in another service category in 2019.  In 2017, 55%of active NMG clients (n=324) were actively enrolled in at least one other service category, 50%(286)in 2018, and 46%(258)IN 2017.  Active is defined as clients who had an open enrollment in eSHARE and received at least one service during the time period.  Percentages represent the proportion of active clients in NMG who were also enrolled and received services in another service category within the year.  A breakdown of dual enrolment by service category by year was provided, with Harm Reduction and Legal Services consistently the top categories.

A summary of the discussion follows:

• Some insured NMG clients may have either Medicaid, Medicare or both.  A very small percentage had private insurance.
• It is possible to determine which program a dually enrolled client first utilized, and which was a referral from that program?
• It would be helpful to know the locations of NMG programs and what other services are offered in those areas.
• NMG is meant to be short-term assistance, and referral/linkage to on-going programs is a service goal.  Half of all NMG clients are enrolled in other RWPA programs that provide equivalent services.
• There are RW Part B programs funded through the State DOH that provide similar services.  Ms. Simon can get data on those programs and dual enrollment with RWPA.
• Viral Load Suppression rates of program enrollees would be helpful, but it will take over a year to get that data.
• Staten Island lacks many of the other programs that NMG clients can access in other parts of the City.
•  The NMG client assessment is generally shorter than other programs, and significantly shorter than Care Coordination, which is an intensive program.
• Health Homes may require Medicaid spend-down (spending down one’s assets until one meets financial eligibility requirements).
• A conversation across programs (RWPA, Part B, Medicaid, etc.) is needed to determine who may lose services in NMG is reduced or eliminated.

Agenda Item #3: Fact Sheets: Mental Health Services (MHV), Harm Reduction (HRM)

Mental Health Services

Mr. Harriman gave an overview of the MSV Goals (Provide treatment and counseling to individuals with HIV and mental illness, with or without co-occurring substance use disorders; Improve quality of life and mental health functioning; Facilitate continued engagement in biological, psychological, and psycho-social care and treatment including adherence to ART and/ or psychotropic medications; Provide mental health navigation and coordination with primary care); and Enrollees (Individuals diagnosed with mental illness or in need of mental health services using DSM criteria; Persons with co-occurring mental health, substance use, and other medical conditions; Individuals with physical, behavioral, psycho-social, or sensory impairments; Homeless/unstably housed or Homebound PLWHA. 

Ms. Biging presented the MSV Fact Sheet.  Highlights include client demographics (by borough, age, risk factor, gender, race/ethnicity) that show an overwhelming majority of clients are Black or Hispanic, and 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 mental health services, RWPA MHV 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, MHV 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 mental health 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:

• Serious Mental Illness (SMI) is defined with specific criteria using DMS diagnoses (e.g., schizophrenia, bi-polar, major depression, etc.).
• Client assistance is typically helping people access benefits and entitlements, housing and other services.
• Is it possible to break down the number of older clients by race/ethnicity?
• It’s notable that there has been a steady, marked decline in spending and number of clients.
• MHV staff who provider clinical services have to be licensed MH professionals, but people who provide support services (e.g., navigation) do not.
• The DOHMH BHIV Care and Treatment Program has created a manual and provided MSV contractors with extensive technical assistance to help them increase provision of navigation and other non-Medicaid reimbursable services. 
• Is there an overlap between HRM and MHV, and are there dual enrollments and service overlap (specifically Alcohol and Drug Counseling services)?  How many newly diagnosed clients (both HIV and MH diagnoses) are enrolling in these programs?
• Is it possible to know the numbers of newly diagnosed (with both mental health and HIV diagnoses) who are enrolling?
• VLS is known to be lower in people with SMI.
• The Needs Assessment Committee (NAC) has been working on SMI issues for a while and will be developing a set of recommendations for improving health outcomes with this population.  The timeline for recommendations to turn into a service directive by IOC and then be implemented should be expedited, especially if any new services will require a procurement (which can take another year).  This long timeline is a good argument for better integrating NAC and IOC.

Harm Reduction Services

Mr. Harriman gave an overview of the HRM Goals (Provide easily accessible harm reduction and substance use services to HIV positive individuals who are actively using or have recently used drugs or alcohol, or are at risk of relapse; Promote access to and maintenance in HI V primary care; Reduce the negative health impacts of drug and alcohol use; and Enhance anti-retroviral treatment adherence.  HRM enrollees eligibility requires current residence in the EMA and household income <500% of Federal Poverty Level.  Priority populations include: Persons with current or recent self-reported problem use of legal and/or illegal drugs and/or alcohol; Persons with current or recent self-reported risk for relapse into substance use; and Persons currently undergoing treatment with methadone, buprenorphine, or some other replacement therapy. 

Ms. Biging presented the HRM Fact Sheet.  Highlights include client demographics (by borough, age, risk factor, gender, race/ethnicity) that show an overwhelming majority of clients (93%) are Black or Hispanic, and over-representation of heterosexuals and residents of the Bronx compared to the general PLWH population.  Older PLWH, Black and Latino cisgender MSM, and cisgender women of color are the most heavily served special populations.

Four years of service unit data shows that Alcohol/Drug Counseling is by far the most heavily used service type, followed by Case Finding, Client Assistance and Client Engagement.  Three years of enrolment data show that the number of unduplicated clients has remained relatively steady, with a small decline in 2019. Spending has fluctuated, and is virtually the same in 2019 as in 2016.  In 2016, HRM spent below their original allotted budget.  Over the following two years, 2017 and 2018, HRM programs have maintained a new modified spending plan each year and have adjusted accordingly.  Each year HRM has increased the units of AOD Counseling, client assistance and engagement, and overdose prevention training.  Most notably, in 2019 HRM greatly increased the units of targeted case finding services delivered.

The intersection between opioid and meth use and HIV has come to the forefront in recent years. Effective July 1, 2018, HRM services were made available to eligible recipients in Medicaid managed care (MMC) and fee-for-service ( FFS) Medicaid f or NYS licensed Syringe Exchange Programs. Currently, this poses no disruption to services, but should be monitored in regards to decreased RWPA HRM spending in the current and coming years.  Medicaid is beginning to play a larger role in reimbursing for harm reduction/ substance use services. NYS Office of Alcoholism and Substance abuse Services (OASAS) offer s crisis services, methadone services, and operates addiction treatment centers.  Additionally, some outpatient and inpatient services are offered through OASAS.  A result of health care reform has been the large push to integrate behavioral and primary health care services.  This aim has been reflected in Health Homes as well as through incentives in the Delivery System Reform Incentive Program (DSRIP). There are some conflicting licensure requirement s for co-located services, specific to Article 31 and Article 32 requirements, but has not yet posed a large issue for our program.

A summary of the discussion follows:

• It would be helpful to have the actual numbers (‘N’) in addition to percentages.
• The State has a Harm Reduction program that focuses on prevention.
• It is possible to add a service type to a contract if it falls within the broader scope in the Council’s service directive.

There was a discussion on the timeline for completing the planning process for the FY 2021 grant application.  Mr. Klotz reported that HRSA has not indicated that the timeline will be adjusted, which means that the Council would need to sign off on the spending request for the application by the by the end of July.  Given the pace of reviewing the service portfolio and the challenges of conducting effective meetings online, one option is to approve a placeholder budget that asks for the maximum allowed by HRSA (5% over the previous year’s award), allocated across the portfolio by rank.  (Certain categories can be held at their current allocations so that the funding is concentrated in areas of higher need.)  Any spending request for the application is not binding, and the Council can continue its review of the portfolio through the rest of the summer, fall and winter, approving a spending plan for the actual award that reallocates funds based on the data reviewed by PSRA.  The other option is to hold additional meetings.

There was a consensus to hold additional meetings and try to get through as much of the planning as possible. 

There being no further business, the meeting was adjourned.