Ryan White HIV/AIDS Treatment Extension Act

Transcription

1 Ryan White HIV/AIDS Treatment Extension Act Administrative Overview Ryan White Part A June 13, 2011 Harold J. Phillips Chief, Northeastern Central Services Branch Department of Health and Human Services Health Resources and Services Administration HIV/AIDS Bureau

2 Welcome and Session Overview Overview of Ryan White Legislation HIV/AIDS Bureau/Division of Service Systems Expectations Grantee Roles and Responsibilities Role of the Project Officer

3 Ryan White HIV/AIDS Treatment Extension Act Largest Federal government program specifically designed to provide services for people living with HIV/AIDS Third largest Federal program serving people living with HIV/AIDS after Medicaid and Medicare Enacted as the Ryan White Comprehensive AIDS Resources Emergency Act in 1990 Amended in 1996, 2000, 2006, 2009 no longer an emergency act

4 Federal Funding for HIV/AIDS Care in the United States, FY 2009

5 Ryan White Appropriations, FY

6 Ryan White Appropriations, FY2009 Total: $2.24 Billion*

7 Revised Purpose of Ryan White Legislation No longer emergency relief for overburdened health care systems Now Revise and extend the program for providing life-saving care for those with HIV/AIDS Address the unmet care and treatment needs of persons living with HIV/AIDS by funding primary health care and support services that enhance access to and retention in care

8 Ryan White Part A Programs Part A: Funding for eligible metropolitan areas (EMAs) and Transitional Grant Areas (TGAs) that are severely & disproportionately affected by the HIV epidemic 24 EMA s* ( 2,000 cases of AIDS reported in past 5 years and 3,000 living cases) 28TGA s (1,000-1,999 cases reported and 1,500 living cases)

9 Key Facts About Ryan White Part A Ryan White services are not an entitlement Ryan White is the payer of last resort Intent is to provide a continuum of care with equitable access throughout the service area Key role for consumers of Part A services through Planning Council and other types of involvement

10 Flow of Part A Funds and Decision Making Federal Government (HRSA/HAB) CEO of EMA or TGA Grantee and/or Administrative Agent Providers Council sets priorities, allocates resources, and gives directives to Grantee on how best to meet these priorities Planning Council Services to PLWH and their Families

11 Grantee and Planning Council Roles and Responsibilities Grantee and Planning Council = two independent entities, both with legislative authority and roles Some roles belong to one entity and some are shared HRSA/HAB recommends separation of duties to avoid confusion of roles Effectiveness requires communications, information sharing, and collaboration between the grantee, Planning Council, and Planning Council support staff and ongoing consumer and community involvement

12 Grantee and Planning Council Roles and Responsibilities Role/Task Planning Council Formation/Membership CEO/ Grantee (CEO) Planning Council Needs Assessment Comprehensive Planning Priority Setting Directives Resource Allocation Coordination of Services Procurement Contract Monitoring Clinical Quality Management (SOC) Cost- Effectiveness and Outcomes Evaluation (option) Assessment of the Administrative Mechanism

13 Needs Assessment Planning Council has primary responsibility and ownership design, direct work or oversight of consultants or volunteers Grantee provides support data, procurement if a consultant is needed, staff assistance Need active community involvement especially consumers and providers Need multi-year plan for assessing needs of PLWH in and out of care Findings go in user-friendly formats as input to decision making, especially priority setting and resource allocation

14 Interpreting the Needs Assessment: Putting the Pieces Together

15 Four Components of Priorities and Allocations Priority setting: deciding what services and program support categories are most important for PLWH in the EMA or TGA Resource allocations: deciding how much Part A funding to provide for each service priority (percent or dollars) Directives to the grantee on how best to meet these priorities e.g., what services for what populations in what geographic areas Reallocation of funds during the program year

16 Priority Setting Planning Council responsibility Means determining what service categories are most important for PLWH in the TGA unrelated to who provides the funding for these services Grantee provides information especially service utilization data and advice, but has no decision-making role Council must establish a sound, fair process for priority setting and ensure that decisions are data based

17 Resource Allocation Planning Council responsibility Process of deciding how much funding to allocate to each priority service category Must meet 75/25% requirement Grantee provides data and advice, but has no decision-making role Need a fair, data-based process that controls conflict of interest Consider other funding streams, cost per client, plans for bringing people into care so some highly ranked service categories may receive little funding Usually use three funding scenarios flat, increase, decrease

18 Planning Council responsibility Directives Providing guidance to grantee on how best to meet the priorities and other factors to consider in procurement Often specify use of a particular service model, or address geographic access to services, language issues, or specific target populations Must not limit open procurement by making only 1-2 providers eligible Council needs to be aware of cost implications Grantee must follow Council directives in procurement and contracting (but cannot always guarantee full success)

19 Reallocation Planning Council role: must approve any reallocation of funds among service categories Reallocation usually means moving funds: From under spent providers to those in the same service category spending at a higher level, or From under spent service categories to those spending at a higher level or with additional need Grantee provides expenditure data by service category throughout the year and requests permission for reallocations as needed Some grantees do regular sweeps or request reallocation permission at set times each year rapid reallocations process very important to avoid unobligated funds

20 Coordination of Services Shared responsibility of grantee and Planning Council Focus on ensuring that Part A funds fill gaps, do not duplicate other services, and make Ryan White the payer of last resort Involves coordination in planning, funding, and service delivery Council reviews other funding streams as input to resource allocation Grantee ensures that providers have linkage agreements and use other funding where possible for example, help clients apply for entitlements like Medicaid

21 Procurement Grantee role No Planning Council involvement Involves: Publicizing the availability of funds Writing Requests for Proposals (RFPs) Using a fair and impartial review process to choose providers Contracting with providers and requiring that they follow standards of care (SOC) and meet reporting and quality management (QM) requirements Contract amounts by service category or sub-category must be consistent with Planning Council allocations and directives

22 Applying Knowledge A grantee staff member is participating in a Planning Committee meeting on needs assessment. The committee is reviewing information on the continuum of care and provider capacity within the TGA, and one member says she would like to know more about the Ryan White providers. She asks the grantee representative to provide copies of information from provider proposals so we can better understand their capabilities. How should the grantee staff member respond? Why?

23 Clinical Quality Management Grantee plays primary role Involves ensuring that: Services meet Public Health Service and clinical guidelines and local standards of care Supportive services are linked to positive medical outcomes Demographic, clinical, and utilization data are used to understand and address the local epidemic Grantee requires providers to develop QM plans, monitors based on quality standards, and recommends improvements Council establishes standards of care for use in QM Grantee reports to Council on QM findings by service category or across categories

24 Applying Knowledge At its most recent Town Hall meeting to hear about PLWH/A service needs, the Planning Council received a lot of complaints about long waiting times for primary care appointments. Two specific providers are mentioned. At the next Planning Council meeting, one member asks the grantee to check this out when you do your QM and contract monitoring visits, and tell us what you find. Is this appropriate? Why or why not?

25 Assessment of the Administrative Mechanism Planning Council responsibility Should be done annually directly or through a consultant Involves assessing how efficiently the grantee does procurement, disburses funds, monitors contracts, supports the Council s planning process, and adheres to Council priorities and allocations Written report goes to grantee, which indicates what action it will take to address any identified problem areas

26 Grantee Staff Roles with Planning Council Attend and make a grantee report at Planning Council meetings Regularly provide agreed-upon reports (e.g., costs and service utilization) Provide advice on areas of expertise without unduly influencing discussions or decisions Assign staff to attend most committees Collaborate on shared roles Carry out joint efforts such as task forces and special analyses consistent with roles and resources

27 Details on the Ryan White Part A Awards Formula is calculated on the basis of living cases of HIV/AIDS cases in the EMA/TGA or Territory in the most recent calendar year as confirmed by CDC and code based data submitted to HRSA Minority AIDS Initiative funding is calculated based upon the number of living minority cases of HIV/AIDS cases in the State or Territory in the most recent calendar year as confirmed by CDC and code based data submitted to HRSA Minority AIDS Initiative funding is used to address disparities in access and retention in care and improve health outcomes for racial and ethnic minorities

28 Details on the Ryan White Part B Awards Supplemental Supplemental funding is awarded through a competitive process based on demonstrated need and the demonstrated success in identifying individuals with HIV/AIDS who do not know their HIV status and making them aware of such status Only those who meet the provisions of the unobligated balances clause are eligible to compete for supplemental funding (formula uob /unliquidated < 5%

29 Legislative Context: Facts and Factors and Major Themes 1. Ryan White program uses a medical model 2. Increased focus on getting people into primary medical care and keeping them in care 3. Limits on non-service costs 4. Focus on ensuring all funds are used - use or lose Part A funding

30 1. Medical Model Major focus on core medical services (medical model) 75% of service funds must be spent on core medical services, newly defined (waiver available) similar requirement in pre-reauthorization Title I program guidances Up to 25% of service funds may be spent on support services that contribute to positive clinical outcomes

31 Ryan White Part A and Part B Core Medical Services 1. Outpatient and ambulatory health services 2-3. Medications: AIDS Drug Assistance Program (ADAP) and Local Pharmaceutical Assistance Programs (LPAP) 4. Oral health care 5. Early intervention services (EIS) 6. Substance abuse services outpatient 7. Mental health services 8. Medical case management including treatment adherence 9. Health insurance premium & cost sharing assistance 10. Home health care 11. Home & community-based health services 12. Medical nutrition therapy 13. Hospice services

32 Ryan White Part A and Part B Support Services Case management (non-medical) Child care services Emergency financial assistance Food bank/home-delivered meals Health education/risk reduction Housing services Legal services Linguistics services (interpretation and translation) Medical transportation services Outreach services Psychosocial support services Referral for health care/supportive services Rehabilitation services Respite care Substance abuse services residential Treatment adherence counseling Services Provided through Consortia*

33 Must be: Support Services 25% of total service expenditures Approved by the Secretary of HHS Needed to achieve medical outcomes Medical outcomes = outcomes affecting the HIV-related clinical status of an individual with HIV/AIDS Support Services must be linked to funded support services that result in positive medical outcomes

34 2. Focus on Getting People into Care Unmet need = need for primary health care among PLWH/A who know they are HIV+ & are not receiving HIV-related primary care Major legislative emphasis on reducing unmet need New emphasis on the unaware population(early Identification of Individuals with HIV/AIDS EIIHA) Improved testing means more people will need primary care and medications Challenge: number served vs. comprehensiveness of services Important changes for long-time consumers

35 3. Limits on Non-Service Funding Focus: maximize funding for direct services 2006 legislation has a 10% administrative cap Planning and Evaluation is capped at 10% Another 5% for Clinical Quality Management assess quality of care and clinical outcomes

36 4. Use or Lose Formula Funding Penalty for unobligated & unliquidated funds If more than 5% of formula funds are unspent at the end of the year ineligible for supplemental funding. Note: MAI is not counted toward the Unobligated Balance (UOB) Unobligated formula balance is used to off set future grant award

37 Factors Affecting HIV/AIDS Services Nationally Epidemic is growing among traditionally underserved and hard-to-reach populations Because of available and emerging therapies, people with HIV/AIDS can live long and productive lives Changes in the economics of health care affect the HIV/AIDS care network Policy and funding increasingly are determined by clinical outcomes and administrative accountability

38 National HIV/AIDS Strategy Three Primary Goals: Reduce the number of people who become infected with HIV Increase access to care and optimize health outcomes for people living with HIV Reduce HIV-related health disparities

39 HIV/AIDS Bureau DSS Expectations How priority issues emerge Legislation National HIV/AIDS Strategy National Factors

40 Priority Issue # 1: Access to Care and Treatment Grantee Roles and Responsibilities Early Identification of Individuals with HIV AIDS Development of realistic and tangible plans Allocation and expenditure of dollars for services that support EIIHA goals and expected outcomes Partnerships and collaborations that help you achieve the intended outcomes Addressing Unmet Need Continued efforts to reach those out of care Service models designed to support the elimination of barriers to care, and increase knowledge regarding HIV disease, and the availability of services

41 Priority Issue # 1: Access to Care & Treatment (cont d) Grantee Roles & Responsibilities Access and retention in care for special populations Identification of special populations for your jurisdiction (EIIHA, PSRA, MAI) Data to increase understanding of their unique service challenges Services designed to reach individuals and families within the context of their Cultural understanding of health care (Part A, Part B, and MAI) Revising and revamping systems of care Enrollment and Eligibility Services such as case management Models such as use of peers, closer ties with testing, partner notification, DIS Chronic care model SCSN & Comprehensive Planning Processes

42 Priority Issue # 2: Access to Medication Therapy Grantee Roles and Responsibilities Dialogue with Project Officers to understanding of the structure, function and enrollment issues of each ADAP Conference Calls Web-ex Video Conferences Diagnostic and Comprehensive site visits Working with States to enhance cost containment and cost saving strategies On site technical assistance TA conference calls Written and electronic materials

43 Priority Issue # 3: Changes in the Economics of Health Care Grantee Responsibilities Understand how the National Economy is impacting health care Grant Applications Progress Reports Monitoring Calls On site technical assistance TA conference calls Written and electronic materials Increase our coordination with Medicaid, Medicare and Third Party Payers Maximize ability to generate and use program income

44 Priority Issue # 3: Changes in the Economics of Health Care Grantee Responsibilities Learn the Affordable Care Act and begin to explore the role of the Ryan White Programs Continued opportunities Challenges Strategic and necessary changes Strengthening of partnerships

45 Priority Issue # 4: Accountability Grantee Roles & Responsibilities Administrative Accountability National Monitoring Standards (program and fiscal accountability) Subgrantee monitoring systems OIG/GAO Audits How do we stewards of federal funds? Data Collection and Reporting Client level data Reporting to Congress Who our programs serve and what we do? Clinical Quality Management Programs Quantitative information on impact and our continued efforts to improve What difference does our program make? Reauthorization

46 Project Officer Roles Track review and approve Grant reporting requirements Conditions of Award Submission of grant request Technical assistance requests Notice of Grant Awards (tracking) Work with Grantees to improve the system of care Needs Assessment Service Planning Service Delivery Service Evaluation Relay and Represent Grantee activities and concerns

47 Summary Changes to the legislation, and the treatment of HIV disease Challenges to the delivery of the HIV services and the need to reach populations in need Outcomes and administrative accountability are important to HHS, Congress, and the future of HIV treatment

48 Structure of The National Monitoring Standards Change is the law of life. And those who look only to the past or present are certain to miss the future. John F. Kennedy

49 Contact Information Harold J. Phillips Chief, Northeastern/Central Services Branch