HCR Issue #2: FY Priority- and Allocation July 17, 2011 Setting Guidance

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1 HCR Issue #2: FY Priority- and Allocation July 17, 2011 Setting Guidance HCR Task Force Guidance for FY Priority- and Allocation-Setting During the summer of 2011 the Commission s Priorities and Planning (P&P) Committee will determine LA County s Ryan White program allocations for FY 2012 (March 2012 February 2013). At the same time, it may need to revise its allocations for the current Ryan White FY 2011 (March 2011 February 2012), once the Health Resources and Services Administration (HRSA) confirms its full FY 2011 Ryan White award to Los Angeles County (delayed due to federal budget negotiations). The Ryan White Program pays for a large share of the medical care and services to low income people with HIV in Los Angeles County. This brief is intended to provide guidance to the P&P Committee, the Commission and the broader HIV community as they deliberate FY 2011 and FY 2012 Ryan White funding allocations for HIV services. Medicaid Coverage Expansion (MCE) Starting in July 2011, and rolled out over the course of the next year, California s Department of Health Care Services (DHCS) and Los Angeles County s Department of Health Services (DHS) will begin enrolling patients at or below 133% FPL into LA County s implementation of California s Bridge to Health Care Reform (1115 Waiver). These programs in LA and other counties called Low Income Health Programs (LIHPs) signal the start of California s Medicaid Coverage Expansion (MCE). As a demonstration project, MCE begins the migration of some current Ryan White patients into a Medi Cal lookalike program three years earlier than nationwide implementation of Medicaid expansion under the Affordable Care Act (ACA). At this time it is still unclear if, how and when patients with HIV will be required to enroll in the MCE. Also, LA County DHS has the option of enrolling patients 134% 200% FPL if funding allows/is available. Healthy Way LA (HWLA) LA County s LIHP is called Healthy Way LA (HWLA). The following criteria will determine if a patient may be enrolled in HWLA: people between years old, who are US citizens or legal residents, and whose incomes are 133% FPL or below. If patients meet these criteria, they are eligible for enrollment into HWLA and assigned to medical homes in July Seniors and Persons with Disabilities (SPDs) All patients with disabling condition diagnoses currently enrolled in Medi Cal are designated as Seniors and Persons with Disabilities (SPDs). Starting in June 2011, SPDs are being transitioned into Medi Cal managed care plans in the month of their birthdays. This does not affect patients with combined Medi Cal/Medicare coverage (Medi Medis) or Medi Cal with a Share of Cost. California s DHCS and its contractor, Health Care Options, have already begun sending information about these changes to eligible patients. Eligible patients should expect to receive initial information three months in advance of their birthdays. LA County s DHS is providing additional information about these changes through its contracted providers. Medi-Cal Managed Care In California, current SPDs, such as people with AIDSrelated disabilities, will be transitioned into Medi Cal managed care plans, rather than current Medi Cal feefor service systems. For many HIV patients in the current Ryan White system, there will be no change, for others, minimal or slight changes, and for others, significant changes that they are encouraged to discuss with their current providers.

2 Page 2 of 11 Ryan White Patients Who May Be Impacted Only current Ryan White patients with incomes 133% FPL or below and who are receiving medical care may be affected by these projected changes in the FY As a result: Uninsured people who are currently receiving Ryan White funded medical care living at or below 133% FPL (still to be determined if, when and how they may be enrolled into LA County s HWLA). People who are currently enrolled in Medi Cal, are diagnosed with AIDS or another disabling condition, and are not currently enrolled in a Medi Cal managed care plan or Medicare (expected to be enrolled into a Medi Cal managed care plan). Ryan White Patients Likely Not To Be Impacted If a patient is receiving Ryan White medical care and living above 133% FPL, his/her provider is not expected to change due to MCE. As part of its Health Care Coverage Initiative (HCCI), DHS may expand coverage to people with incomes up to 200% FPL if funding is available. If a patient is disabled due to HIV/AIDS or another disabling condition, he/she should (generally) already qualify for some combination of Medicare/Medi Cal services and should not (generally) be receiving Ryan White funded medical care. Their service providers are not expected to change due to MCE. If a patient is an undocumented resident and/or has been naturalized in the last five years, there should be no change due to MCE. Although health care for undocumented or recently naturalized residents is not be covered by the ACA, and they will continue receiving services in their current systems of care. If a patient is receiving medical care funded by in part or in whole Medicare or another non Medicaid/ non County health plan, his/her health care status should not change. There are currently no plans to alter other forms of healthcare coverage before If a patient is already in a Medi Cal managed care plan (including Kaiser or AHF s Positive Living), no changes are expected as a result of MCE. Future Medi-Cal-Eligible Ryan White Patients It is difficult to ascertain how many patients are already Medi Cal eligible (pre July 2011) and continue to access Ryan White funded medical care. All patients should be screened for Medi Cal financial eligibility when they enter care and annually thereafter. ADAP requires the same type of annual screening. Although there may be current Ryan White patients who should be more appropriately enrolled in Medi Cal, it is estimated that the number is negligible due to repeated screenings and assessments. It is estimated that 60 70% of current Ryan White patients live at or below 133% FPL and will become eligible for enrollment into HWLA in FY The Office of AIDS Programs and Policy (OAPP) has recently estimated that there are 6,000 patients of the approximately 15,000 patients in Ryan White funded medical care who could be enrolled in HWLA in the next year, if and when federal, state and county policy makers determine that persons with HIV be required to move to the LIHP. Enrolling Ryan White Patients Into HWLA Neither the State s DHCS nor LA County s DHS have yet announced how they will enroll patients with HIV who currently receive Ryan White funded care into HWLA in FY Federal statute dictates that Ryan White funding should only be used as a last resort when there are no other sources of funding for services and patients should be enrolled first in the LIHPs if they are eligible. Implementation details are forthcoming. Final.doc Page 2 of 11

3 Page 3 of 11 Further complicating these decisions is that several current Ryan White providers are not HWLA providers and/ or have not yet made arrangements to become part of Medi Cal managed care networks. Some Ryan White medical outpatient clinics claim that the rates they would be paid as part of HWLA and/or Medi Cal managed care networks are insufficient to cover the costly care for HIV patients that is currently reimbursed through Ryan White, and would require lowering the number of patients they can serve. In either case, failure to properly prepare providers and patients for the migration of current Ryan White funded HIV patient populations to other systems could lead to significant disruption in the lives of HIV patients. Priority- /Allocation-Setting Guidance Given the uncertainty about how the local HIV health care system will change in the next year and a half, the priority and allocation setting for FYs 2011 (potential revisions) and FY 2012 will require more sensitivity to client numbers, funding availability and service utilization. Contingency Planning The two principle drivers of allocation changes in the upcoming years will be the projected number of patients/ clients and the amount of funding available. RECOMMENDATION #1: FY 2011 allocation revisions may or may not necessitate significant contingency planning because the Ryan White fiscal year may be half over by the time HRSA announces final FY 2011 Ryan White awards. Service utilization patterns and some analysis of implementation variables to date will better dictate if and what revisions to FY 2011 allocations are necessary. RECOMMENDATION #2: Because so many variables are still unknown and/or developing, the Health Care Reform Task Force (HCR TF) recommends that the Priorities and Planning (P&P) Committee determine variable allocations for FY 2012 (contingency planning) based on the two principle drivers. Patient Migration to Other Health Care Systems: The number of patients/clients who will receive Ryan White funded medical services may decline by an unknown amount in 2011 and 2012 due to the implementation of Bridge to Health Care Reform (the 1115 Waiver). While OAPP has estimated that up to 6,000 patients currently receiving Ryan White funded medical care may be eligible for enrollment in HWLA, that estimate may vary due to residency status, income screening and other variables. Additionally, how and when patients who are eligible for HWLA will be identified, how and when their enrollments into HWLA will be processed/accepted, what services patients will be able to access in HWLA, what services they will continue to rely on from the Ryan White funded system, and if any gaps in care develop, are all significant factors that will dictate how many patients will remain in Ryan White funded medical care and other services in FYs 2011 and Likewise, although 1,000 2,000 patients enter/return to Ryan White funded medical care annually, that figure may decline due to enrollments into HWLA or may rise due to enhanced efforts to identify and enroll people with HIV into care. RECOMMENDATION #3: While OAPP has estimated that up to 6,000 current Ryan White funded patients/ clients may be eligible for HWLA enrollment, due to variables in implementation, timing, enrollment, financial screening, residency and other factors, the HCR TF does not estimate that the entire number will be enrolled in HWLA by 2012, especially from the outset of enrollment eligibility. Due to those variable factors, however, the HCR TF cannot yet estimate when and how many clients will be enrolled in HWLA with more reliable accuracy. As a result, contingency plans are needed to more accurately plan for FY The HCR TF recommends contingency plans based on 5,000 patients leaving Ryan White funded medical and related services; a decrease of 2,500 patients; and, 1,000 or fewer clients leaving Ryan Whitefunded medical care. Final.doc Page 3 of 11

4 Page 4 of 11 Funding Picture: The total amount of the Ryan White funding is always an unknown variable, both because of federal funding levels and LA County s supplemental Ryan White application score (based on LA County s and other jurisdictions performance on the application). Although it is not possible to predict the supplemental application score, LA County s supplemental application has consistently ranked among the best in the country; more variation has been due to the performance of other jurisdictions in comparison. Likewise, it is important to note that in the past decade, LA County s Ryan White award has not declined by more than 10%. While the federal Administration has asserted and sustained a commitment to HIV services to date, due to ongoing federal cost expenditure negotiations, the FY 2012 funding level is more unpredictable. It t is not certain that the Administration s financial commitment to Ryan White can be maintained when overall federal budget reductions are expected in federal FY (October 2011 September 2012). Any future federal reductions in Ryan White funding are also likely to impact Part B funding to the state s Office of AIDS (OA), from which LA County derives approximately $10 million annually for local HIV services. A federal reduction in other Part B funding could result in a loss of Part B funds for LA County. Although the federal Administration has demonstrated a very strong commitment to ADAP (also Part B funded), there are no assurances that there will be additional ADAP funds in the future or that additional ADAP funding will come to California. California s budget picture is as precarious as federal budget scenarios. While, to date, the Governors and the State Legislature have preserved most ADAP funding in spite of enormous budget cuts to other state health and human service and HIV programs, that commitment cannot be guaranteed into the future. Preservation of ADAP funding in this year s state budget relies, for example, on some one time only federal funds and cost savings that the ADAP program has realized. Likewise the recently passed State budget relies on specific revenue levels, that, if not reached, could trigger deeper health and human service cuts. While it is possible that ADAP may realize further savings in future years as patients migrate into LIHPs, it is likely that those savings will be used to reduce the State s general fund contribution to ADAP, as they have been in the past not necessarily to make more funding available for other HIV services. Assessing the political and funding landscape, the HCR Task Force considers a Ryan White funding increase to LA County in FY 2012 doubtful. Given that LA County s Ryan White application is consistently ranked among the top applications in the country, it is unlikely that a better score on the supplemental application can earn the County significant additional Ryan White dollars. Thus, additional Ryan White funding would most likely only result if additional federal funds are allocated to the Ryan White Part A or B programs also improbable in the current state and federal budget climate. RECOMMENDATION #4: It is possible that the decrease in clients may balance any reductions that result from federal and/or state budget cuts. However, the possibility of federal and state cost reductions unraveling service category allocations necessitates contingency plans based on modified funding levels. The HCR TF recommends that the P&P Committee vary its allocation plans based on the possibility of decreased funding levels, perhaps reductions in 5 7 percentiles: e.g., 5%, 10% and 15% or more reductions; or 7% and 14% or more reductions. RECOMMENDATION #5: Given the remote possibility of a Ryan White funding increase to LA County in FY 2012 and the complexity of the P&P Committee s allocationsetting deliberations, the HCR Task Force recommends that the Committee focus its allocation setting in the funding scenario variations detailed in the previous recommendations rather than planning for an increase. Ultimately, if there is a net Ryan White funding increase in FY 2012, the P&P Committee will be better suited to consider how to use those funds at that time, after more information is known about patient migration patterns and federal/state budget discussions have advanced further. Final.doc Page 4 of 11

5 Page 5 of 11 Of course, multiple contingency plans based on multiple variables requires a more complicated allocation setting process for FY 2012 than the Commission has ever encountered before mirroring the complexity of the LA County health care system transformation anticipated in the next several years. In a healthcare environment where the one constant will be future change, the more precise the planning, the better prepared the Ryan Whitefunded system will be able to accommodate that change. While it is possible that the effects of some federal and/ or state cutbacks could be mitigated by local Ryan White Program savings from the migration of patients to other systems of care, it is not possible to understand or plan for those effects unless the allocations process considers both factors, and how they intersect, in multiple funding scenarios. Similarly, the HCR TF understands but does not address in the context of this guidance that other factors will also drive allocation strategies: adherence to the National HIV/AIDS Strategy goals, increased emphasis on early identification of people with HIV and their linkages to care; introduction of linked biomedical prevention/care approaches into medical practices; identified and/or emerging gaps in care/treatment, and current service utilization patterns and trends, among others. Under HWLA, LA County s DHS will provide primary care and specialty services at County DHS clinics/facilities or other community providers [previously funded under the Public Private Partnership (PPP) Program]. All providers under the PPP/HWLA ( matched / unmatched ) program will provide patients with a medical home (another provision of the ACA). Service Categories All HIV service categories will be impacted to some degree by reductions in state or federal funding. Multiple service category allocations will be also be affected by partial or significant migration of patients from Medi Cal fee for service to Medi Cal managed care, and from the Ryan White funded system to HWLA. Following are a list of the service categories [ranked in FY 2011 priority order (accompanied by their priority rankings) as core medical or support services] that the HCR Task Force believes will be most impacted by anticipated changes resulting from LA County s implementation of Bridge to Health Care Reform and projected funding levels. The following list, however, does not identify all service categories that may be affected by multiple variables over the next two years only those it believes may be most significantly impacted. Each of the following service categories is accompanied by an explanation of the possible patient migration/funding level factors that may require adjusted allocations for those service categories. In some cases, specific recommendations follow; in the others, the HCR TF recommends that the P&P Committee consider possible allocation shifts in light of the factors described and in the context of the recommended contingency scenarios. Core Medical Services: Medical Outpatient/Specialty (Priority #1): Approximately half of the available Ryan White Part A and B funding in LA County is allocated for Medical Outpatient/Specialty services. HWLA and Medi Cal managed care are both responsible for responding to all of the medical needs of eligible patients. As a result, it is anticipated that as the number of patients enrolled in Ryan White funded medical care declines, the amount of funds allocated to this service category can be reduced commensurately. Provided the numbers of new/returning number clients to and leaving the Ryan White funded system (not those who are enrolled in HWLA) remains stable through 2012, the net number of patients currently enrolled in Ryan White funded medical outpatient services will decrease by the number of patients who are migrated into HWLA. Ryan White Medical Specialty services are paid for by funds allocated for Medical Outpatient/Specialty. Traditionally, OAPP has contracted with a private provider to provide medical specialty access to other contracted private providers, but reports are that the funding is Final.doc Page 5 of 11

6 Page 6 of 11 insufficient to cover the current need. Patients receiving Ryan White funded medical care at County clinics and patients at private clinics can access specialty services through the County s health care system, although reports indicate that medical specialty wait times are too prolonged. Additionally, it is reasonable to expect that the addition of 100,000+ new clients to HWLA (DHS estimates) will further stretch County specialty resources and necessitate an increased allocation of Ryan White funds for medical specialty services to people receiving Ryan White funded services. RECOMMENDATION #6: The HCR TF recommends that the P&P Committee review the spectrum of specialty services that are available, the degree to which each type of specialty care meets current patient demand (especially in light of demographic changes, such as the aging HIV population), and determine if there is specialty care that is currently not covered, but needed (e.g., optometry). Medication Assistance and Access (MA&A) (Priorities #2 and #5): Details about how medications for patients who migrate to other systems of care will be covered must still be clarified. Medications for patients in the local Ryan White funded system of care are largely covered by California s Part B funded AIDS Drug Assistance Program (ADAP). Previously, the Commission has also allocated supplemental funds to medical outpatient for Local Pharmacy Programs/Drug Reimbursement (LPP/DR) making partial funding available to clinics to provide additional medications, as needed by patients and not on other formularies. LPP/DR is now called Medication Assistance and Access (MA&A). As patients migrate to Medi Cal managed care plans and HWLA, those systems will become responsible for providing their patients with the medications they need. Each managed care plan and HWLA has a formulary which dictates the medications/prescriptions that they can provide their patients. However, the ADAP and HWLA formularies may differ. As of yet, it is not certain which formulary HWLA will rely on, but is assumed that it will mirror the current Medi Cal formulary (Medi Cal managed care plans must provided medications on the Medi Cal formulary). Most providers consider the Medi Cal formulary sufficient for the pharmaceutical needs of people with HIV/AIDS. Federal, state and county policy makers are trying to determine if providers/patients will be able to access ADAP for medications/prescriptions not on HWLA s or individual plans formularies. The P&P Committee should determine the degree to which its current MA&A allocation sufficiently meets the need and, then, depending how and which formularies apply, may need to adjust its MA&A allocation accordingly. If it is determined that HWLA s and managed care plan formularies adequately cover HIV/AIDS patients medication needs and/or it is determined that ADAP can be used to address any gaps in medication coverage, then the P&P Committee may decide to sustain or reduce its limited MA&A allocation. Alternately, if there are large gaps in medication coverage and/or ADAP cannot be used to fill those gaps, the P&P Committee will need to increase its allocation for MA&A. Modifications to this allocation will also be driven by how many patients are migrated from the Ryan Whitefunded care to other healthcare systems, and any medication co payment requirements. Similarly, as responsibility for medications are shifted to other systems of care, the pharmacy and dispensary structures may also change which could significantly impact pharmacy access. Currently, medications funded by ADAP are available at a vast network of pharmacies/dispensaries throughout California. However, HWLA patients may only be able to access those medications through County pharmacies/dispensaries limiting where patients can get those medications. Similarly, County pharmacies/dispensaries would have to adjust their inventories to meet the demand for HIV medications. While there are potential solutions such as an HWLA Pharmacy Benefits Manager none have been implemented yet. The Commission will need to monitor potential challenges in pharmacy access and consider ways of addressing it (e.g., increased MA&A and/or transportation support) through its allocations. Final.doc Page 6 of 11

7 Page 7 of 11 Oral Health Services (Priority #3): The P&P Committee has already determined that allocations for oral health care do not yet meet patient need, in spite of successive, increased allocations for the service in each of the past five years. Multiple LACHNAs (LA Countywide HIV Needs Assessments) have established that there is a continuing wide gap between need for oral health care and availability of oral health services, which has only been exacerbated in recent years by the State s elimination of DentiCal. To a certain extent, the Commission s allocation increases have been limited by how fast the system can expand the number of oral health care providers and their capacity to serve new patients with extremely complex dental conditions. For those reasons, the Commission allocated one time Minority AIDS Initiative (MAI) roll over funds for the purpose of expanding current Ryan White oral health capacity. Given those funds should be used in 2011, the P&P Committee will need to increase its oral health allocation simply to sustain current oral health funding levels. The LIHPs and Medi Cal are only responsible for emergency or medically necessary dental care [although some of the agencies in HWLA are FQHCs (Federally Qualified Health Centers), which are required to provide a full range of oral health care]. It is expected that the need for oral health services will continue unabated, requiring additional allocations to meet demand. RECOMMENDATION #7: Increase the allocation for oral health care to sustain current levels of oral health care funding and to continue improving system ability and capacity to meet oral health care needs. Health Insurance Premiums/Cost Sharing (HIP/C S) (Priority #4): HIP/C S is a service category implemented for the first time in FY 2011 in order to provide additional financial assistance to HIV patients/clients in other current or future systems of care. While the parameters of the program are still being defined, it may include but is not limited to co payments and/or cost sharing measures to improve patient access to medical/support care; premium payment support for the current PCIP, future health insurance exchanges, and/or private insurance; and/or co pays for medications. It is expected that implementation of cost saving measures and/or possible additional eligibility requirements will dictate the type of assistance this service category funds. In addition, the P&P Committee should pay close attention to new services provided through the State s OA/HIPP program in order to reduce redundancy/duplication of services. Medical Care Coordination (MCC) (Priority #7): FY 2012 is scheduled to be the first full year of MCC implementation. The local MCC model is consistent with the medical home requirement in the ACA and the 1115 Waiver. Like the medical home concept, MCC ensures that patients have a primary provider team which coordinates the patient s care and treatment service delivery (including support services). Because patients will be migrated to other healthcare systems obligated to provide them with medical homes, the necessity for Ryan White funded MCC services may decline. However, MCC may continue to play a central coordinating role for patients receiving medical and related care in other health care systems while continuing to receive additional medical and/or support services in the Ryan White system. It can be argued that coordinating care between two systems may be more costly and time consuming. Both alternate scenarios may necessitate sustained or increased MCC allocations. Mental Health, Psychiatry/Psychotherapy (Priorities #8 and #9): The LIHPs and Medi Cal managed care plans are responsible for providing mental health care to their patients. HWLA s mental health services will be provided by the Department of Mental Health (DMH), but specifics of those services are not yet available. While some Ryan White funded mental health need may decline as clients migrate to other systems of care, reports indicate that mental health is underfunded. Additionally, mental health services provided by HWLA and the managed care plans may be capped at specific numbers of visits, resulting in continued need by some clients in those systems of care. Final.doc Page 7 of 11

8 Page 8 of 11 Early Intervention Services (EIS) (Priority #11): EIS programs identify and link patients into care with a programmatic emphasis on retention in care. The Standards of Care (SOC) Committee has begun evaluating EIS program design to ensure program model consistency and strengthen the medical home component. In the meantime, the P&P Committee may have to consider EIS program models in which patients receive their medical services in other systems of care and/or a reduced patient caseload due to patient migration to other systems of care. Fewer patients and services may suggest a reduced need for EIS allocations. RECOMMENDATION #8: The allocations for EIS and Outreach will need to be considered concurrently as program designs need to be adjusted to consider a greater emphasis on identifying new patients who are ultimately enrolled in other systems of care rather than Ryan White funded medical care. Substance Abuse, Treatment (Priority #15): The need and availability of substance abuse treatment services must continue to be monitored concurrent with HCR implementation. At the time of this publication, it is not yet clear if other plans/systems are required to assume responsibility for substance abuse care and not yet known if and how those other health care plans/ systems will address patients substance abuse needs. Similar to mental health, if program service caps or limitations are imposed, service need may continue or increase. Likewise, State budget cuts could also impact LA County Substance Abuse Prevention and Control (SAPC) service availability, necessitating possible allocation increases for these services. Skilled Nursing/Hospice (Priority #20 and #22): All alternate health care systems (Medi Cal managed care and HWLA) provide hospice and skilled nursing services, when appropriate, for covered patients. Similarly, as patients require these services, payment for that care is often transferred to Medicare. As a result, the need for Ryan White funded hospice and skilled nursing services may decline commensurately with Ryan White patient counts. Alternately, an aging patient population may indicate increased need for hospice/skilled nursing services for clients remaining in Ryan White funded medical care. The P&P Committee will need to determine what level of hospice/ skilled nursing allocations are needed in light of these variables. Changing allocations to this service category may similarly impact residential services, where some skilled nursing needs are currently met. RECOMMENDATION #9: Hospice and skilled nursing programs in HWLA and Medi Cal may vary widely from the current services in the Ryan White system. The P&P and SOC Committees should assess and reconcile the service structures in those systems, determine if those systems have sufficient capacity to meet the projected demand from HIV patients, and determine if and how Ryan White funds can be used to supplement those services in other systems of care if they are determined to be insufficient. Support Services: Benefits Specialty (Priority #6): Benefits Specialty was first funded last year to provide a secondary, more advanced level of response to ensure patients/clients can fully maximize other public benefits programs. In the Ryan White funded system of care, case managers and medical care coordination case workers are expected to initially assist patients/clients with enrollment into other benefits programs. However, complex individual care sometimes necessitates support by personnel who specialize in benefit programs to help individual patients/clients navigate unusually complicated application and/or enrollment processes. The Standards of Care (SOC) Committee has recently raised the concern that the increasing complexity of Health Care Reform/ Bridge to Health Care Reform application and enrollment processes may demand more specialized benefits expertise than originally envisioned. That may require an increased allocation for Benefits Specialty services. Final.doc Page 8 of 11

9 Page 9 of 11 Residential Services (Priority #13): Because OAPP has determined that many of its patients requiring skilled nursing services are actually receiving those services through residential care, rather than in specific skilled nursing facilities, any determinations or changes to hospice and skilled nursing services may impact residential services similarly. RECOMMENDATION #10: The HCR TF recommends that the P&P Committee consider allocations for Hospice/ Skilled Nursing services and Residential Services concurrently. Outreach (Priority #24): The Commission announced that it intends to fund Outreach as a separate service category for the first time in FY Outreach services are targeted for patient populations not receiving adequate medical care, who have fallen out of care, and/or who are not aware of their HIV status; outreach services can be provided as stand alone programs or used to supplement existing care and treatment services. Since outreach has not been previously funded as a service category, adequate funding levels will be difficult to determine initially. However, additional outreach needs may be identified if gaps in care result from migration of patients to alternate health care systems. Similarly, many of the outreach services performed previously as part of EIS services may need to be funded separately as new patients are identified and enrolled into other systems of care rather than Ryan White funded care. Related Allocation Issues There are a number of other allocation issues that must be reviewed and/or revisited in light of the rapidly evolving HIV health care service system transformation. These issues are addressed in the following section and are accompanied by HCR TF recommendations. Core Medical Services Threshold: In 2006, a new provision was added to Ryan White legislation mandating that Part A funded Eligible Metropolitan Areas (EMAs) must allocate and spend at least 75% of their Ryan White funds on core medical services. EMAs that cannot meet that threshold are entitled to request an exemption if they can prove that those medical services are guaranteed through other resources. The Los Angeles County EMA has traditionally allocated and expended more than 80% of its Ryan White funds on HRSA identified core medical services. However, in upcoming years, the percentage of funds dedicated to core medical services may decline as a significant proportion of Ryan White patients begin receiving medical care from other health care systems (e.g., HWLA, Medi Cal, Medi Cal managed care, PCIP, health insurance exchanges, and private insurance). Following possible revisions to Ryan White legislation in/after 2013, the equation of medical/ support services may change substantially. However, until then, the Commission must consider the impact of the Bridge to Health Care Reform on the EMA s ability to continue meeting the core medical 75% threshold. Like all other aspects of FY 2012 priority and allocationsetting, continued fulfillment of the core medical threshold will depend on the twin drivers of patient migration and future funding levels. Accordingly, LA County may need to submit a request to be exempted from the core medical threshold to HRSA. If, for example, few patients migrate to other systems of care in the short term future, an exemption will not be necessary. If, on the other hand, a large number of patients migrate to other care systems and Ryan White funding levels are reasonably sustained an exemption may be necessary. If a large number of patients migrate out of Ryan White care, but Ryan White funding levels are also significantly reduced, the exemption may not be needed. The P&P Committee must determine in the various contingency scenarios what patient migration and funding levels will dictate the need for an exemption. RECOMMENDATION #11: The P&P Committee needs to evaluate if and when it should submit a request to be exemption for the 75% core medical threshold to HRSA. It should review the possible contingency scenarios and Final.doc Page 9 of 11

10 Page 10 of 11 project what patient migration and funding levels may trigger the need for that exemption. It must also determine if, and under what circumstances, it can request the exemption prospectively (e.g., in case certain local conditions result in Ryan White expenditures for core medical service dropping below the 75% requirement). Minority AIDS Initiative (MAI): MAI funds are Ryan White Part A resources allocated specifically to enhance HIV services for minority populations [e.g., African Americans, Latinos/as, Asian Pacific Islanders (APIs)]. MAI funded services are intended to increase service availability to minority populations and/or to expand minority access to HIV services. In 2006, the Commission approved a plan that allocates MAI funds for three service categories: oral health, EIS, and medical case management (which becomes Medical Care Coordination in 2011). MAI funds have been used since then for additional services for minority HIV patients in those three service categories. In light of Bridge to Health Care Reform, those service categories may or may not be the best use of MAI funds to ensure access and service availability for minorities with HIV as they migrate to other systems of care. RECOMMENDATION #12: The HCR TF recommends that the P&P Committee initiate a review of the MAI plan to determine the suitability of current MAI allocations in the current environment of health care transformation. The review will help the P&P Committee determine if the service categories to which MAI funds are currently allocated are the best MAI response given the changing circumstances of the Ryan White system, and/or if the accompanying allocation levels are appropriate, or if shifts in MAI funded service categories/allocations consistent with shifts in health care services are necessary. Service Planning Area (MAI) 1 Allocation Threshold: In 2009, the Commission approved a minimum allocation of $1,180,000 to provide specific services to patients/ clients in SPA 1. The Commission reasoned that fewer providers, a lower proportion of healthcare resources for low income HIV patients/clients in the SPA, greater poverty and disenfranchisement, and other factors contributed to a greater need for Ryan White funded services in SPA 1 than other parts of the County. In response to this analysis, the Commission approved a minimum allocation to ensure adequate access and availability of basic HIV services in this expansive, largely rural geographic area. However, migration of patients into HWLA and MCE has the potential of altering the service mix, increasing healthcare coverage for patients with HIV, expanding the number of providers, and enhancing the availability of services in SPA 1. Similarly, surveillance and patient level health data was not fully adequate in 2009 to determine the extent of un or under served people with HIV in the SPA; that data has improved significantly since then and may lead to fresh projections of service needs. The resulting impact of these changes may modify, reduce or remove the necessity of a minimum allocation to this region. RECOMMENDATION #13: The HCR TF recommends that the P&P Committee review its minimum allocation for SPA 1, in the context of projected changes to the HIV healthcare in the region. The P&P Committee should update the formula it used to justify the threshold allocation with improved available surveillance and health data, and incorporate health care reform factors detailed in the preceding text to determine if a threshold allocation is still needed, and, if so, if it is necessary to modify the allocation level. Priority and Allocation Setting Directives: The Commission is entitled to accompany its priorities and allocations with directives to OAPP and other system partners on how best to meet the need and other factors to be considered. Those directives help the grantee align its procurement and service delivery activities with the allocation, service coordination and continuum of care decisions made by the planning council. The Ryan White system will be confronted by unfolding developments in the Bridge to Health Care Reform like never before. Emerging health care reform issues will Final.doc Page 10 of 11

11 Page 11 of 11 require a system responsiveness that will, at best, challenge County and State publicly financed health care. Evolving consumer, provider and systemic needs in this health care transformation may necessitate unprecedented system alacrity. On the one hand, service implementation in a rapidly changing health care environment without a sufficient plan or framework can render care and treatment delivery ineffective and counter productive. Alternatively, flexibility to respond to emergent needs can be hindered by planning decisions that are too restrictive or a decision making process that cannot respond quickly enough. Similarly, data on emerging service delivery patterns or utilization trends is rarely real time, and often necessitates swift response once those patterns and trends have been identified. The P&P Committee must consider ways to determine allocations and directives that provide a coherent and cohesive implementation plan while giving the grantee maximum flexibility to respond to rapidly evolving needs and complexities. RECOMMENDATION #14: Among other directives the P&P Committee may generate, it should also develop directives providing guidance to the grantee detailing how and under what circumstances the grantee can independently modify allocations and/or alter service delivery strategies to ensure the most effective response to consumer care needs. Those directives may detail variable or re allocations, rapid response tactics, program design modifications or any number of other possible strategies designed to yield the smoothest and most seamless healthcare transitions possible for HIV patients/ clients. Written by: Reviewed by: Craig Vincent Jones Julie Cross Phil Curtis Aaron Fox Nettie DeAugustine Michael Johnson John Schunhoff Carlos Vega Matos Final.doc Page 11 of 11