Meeting of the Priority Setting & Resource Allocation Committee
Monday, April 11, 2022
By Zoom Videoconference
3:05 – 4:55
Members Present: Marya Gilborn (Co-chair), Jeff Natt (Co-chair), Fulvia Alvelo, Matt Baney, Paul Carr, Billy Fields, Joan Edwards, Matthew Lesieur, Guadalupe Dominguez Plummer, Leo Ruiz, Terry Troia
Members Absent: Eunice Casey, Broni Cockrell, Graham Harriman, Henry Nguyen, Michael Rifkin, Claire Simon, Victor Velazquez, Dorella Walters
Staff Present: David Klotz, Scott Spiegler, Melanie Lawrence, Johanna Acosta, PhD, Deborah Noble, Karen Miller, Nadine Alexander, Renee James, Grace Herndon, Kimbirly Mack, Dave Ferdinand, Tye Seabrook, Tigran Avoundjian (NYC DOHMH); Gemma Barclay, Arya Shahi (Public Health Solutions)
Guests Present: Diane Tider (Mt. Sinai Medical Center); Maria Rodriguez, Yarilda Santos, Daniel Lowy, Client (Argus Community Services)
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 April 11, 2022 meeting were approved with no changes.
Agenda Item #2: Planning for GY 2023
Mr. Klotz explained that the PSRA Committee will need to decide on an allocation for the services in the Council-approved Aging & HIV directive, which will start in March 2023. With the likelihood of continued reductions to the award, funds for that and other obligations (a full year of Oral Health funding, absorbing a cut to the award) needs to come from somewhere in the existing portfolio. PSRA has discussed the possibility of reducing the Medical Case Management/Care Coordination (MCM) allocation due to payer of last resort issues. The Recipient staff has developed an analysis of the cost of the Aging & HIV program, as well as a recommendation for addressing the MCM allocation.
Aging & HIV Allocation
The Aging & HIV Service Directive includes two distinct new service categories: Ambulatory Outpatient Services (AOS), and Referrals to Health and Support Services. Dr. Acosta presented the HRSA definition for AOS and a summary of the service in the Council’s directive (where it is called Outpatient Medical Care). The service types in AOS include intake and reassessment, service plan development and update, outpatient ambulatory services (STI and hepatitis screening/testing, geriatric assessment including cognitive, cardiac screening, etc.), and referrals. The possible staff and license/degree requirements were explained (physician, physician’s assistant, nurse practitioner, nurse, medical assistant, pharmacist, pharmacy assistant). A staffing plan with proposed salary ranges for each position showed that each program would cost between $283,883 and $302,198. The Recipient recommends starting with three programs that would serve 30-50 clients each, using a cost-based reimbursement structure.
A summary of the discussion follows:
- Salaries are based on common salary ranges from public sources and increased to address pay equity issues.
- The EMA funded services in this category in the early 2000s (although targeted to people living in SROs) and found that performance-based reimbursement was too problematic. Performance-based contracting does not provide for adequate reimbursement for medical services.
- A full-time employee for data entry will be required due to the extra data requirements and reporting for this category.
- A half time medical provider is appropriate because the medical case manager will be doing most of the assessment and service plan development, as well as navigation and referral work to non-HIV care.
- All programs would be required to assess payer of last resort issues by checking all client’s enrollment in Medicaid, Medicare and other programs and by seeing if they are receiving the same services elsewhere.
- The optimal maximum number of clients per medical case manager should be 20:1.
Referrals to Health and Support Services
Dr. Acosta presented the HRSA definition of this category and a summary from the Council’s Aging & HIV directive. There are 7201 clients in the RWPA age 50 and older. Referrals for this population would necessitate numerous specialists to adequately address the referral needs within this population. Referrals for health and supportive services already occur in the majority of RWPA programming and this service type is included within MCM and the new AOS categories. Referrals made in another service category must be data entered and reimbursed under that service category, and funds cannot be used to duplicate referral services provided through other service categories. Based on focus group data, in 2019 the Recipient hired a consultant and worked with AETC to produce a training on navigation services and coordination of care for OPWH. Over $100,000 was spent on the development of online training curriculum and resource directory focused on care navigation for OPWH beyond HIV medical care with a focus on geriatric, neurological, and other types of care necessitated by population.
The Recipient proposes to utilize aspects of the ARTAS EBI through the establishment of MOUs across the RWPA portfolio. Also, HRSA prohibits the use of service dollars for creation of a resource directory. The NYC HealthMap is currently being enhanced and expanded at the agency level, and the Recipient will require subrecipients to complete the currently offered OPWH online training. The Recipient will also provide TA on the utilization of OPWH resource directory across the RWPA portfolio. Thus, given the requirement to avoid duplication of services, no additional allocation will be needed to implement the Referrals portion of the Aging & HIV directive.
A summary of the discussion follows:
- There are many more OPWH in the EMA (2021 surveillance report shows about 77,000 in NYC) beyond those enrolled in RWPA programs. Many will be RWPA eligible and could benefit from referrals.
- The Recipient pledged to ensure that all elements of the directive are implemented through the existing RWPA portfolio.
- 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.