Ryan White HIV/AIDS Treatment Extension Act Administrative Overview Ryan White Part A

1. Ryan White HIV/AIDS Treatment Extension ActAdministrative Overview Ryan White Part A July 29-31, 2013 Steven R. Young, MSPH Director, Division of Metropolitan HIV/AIDS Programs U.S. Department of Health and Human Services Health Resources and Services Administration HIV/AIDS Bureau

2. Welcome and Session Overview • Overview of Ryan White Legislation • Grantee Roles and Responsibilities • Role of the Project Officer • Expectation of the HIV/AIDS Bureau/Division of Metropolitan HIV/AIDS Programs • Impact of the Affordable Care Act and Reauthorization

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

4. Ryan White HIV/AIDS Treatment Extension Act • Enacted as the Ryan White Comprehensive AIDS Resources Emergency Act in 1990 • Amended in 1996, 2000, 2006, 2009– no longer an “emergency” act

5. FY 2013 Ryan White HIV/AIDS Program Appropriation, Nearly $2.25* Billion *Includes Emerging Communities and Part B base. Source: HAB/HRSA Budget Office

6. Revised Purpose of the 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”

7. Ryan White Part A Programs Part A: Funding for eligible metropolitan areas (EMAs) and Transitional Grant Areas (TGAs) that are severely and disproportionately affected by the HIV epidemic • 24 EMAs* (≥2,000 cases of AIDS reported in past 5 years and ≥3,000 living cases) • 29 TGAs (1,000-1,999 cases reported and ≥1,500 living cases; changed to at least 1,400 cases if funds awarded are not more than 5% unobligated)

8. Local planning and prioritization of funding based on needs assessment Involvement of people living with HIV/AIDS (PLWHA), “consumers,” in planning process Primary care and support services funded Quality of care Basic Tenets of Ryan White

9. Ryan White HIV/AIDS Program:Clients Served Over 553,000 uninsured and underinsured persons affected by HIV/AIDS annually (CY 2011) Approximately 244,437 people received medications through ADAP in CY 2012 1 in 4 receiving ARVs in U.S. use ADAP services Reach those most in need, with an estimated 72 percent racial minorities, 30 percent women, and 87 percent uninsured/underinsured or receiving public health benefits (CY 2011)

10. Ryan White HIV/AIDS Programs Cities (Part A) States and Territories (Part B) AIDS Drug Assistance Program (ADAP) Health Care Agencies Early Intervention Services and Capacity Development (Part C) Women, Infants, Children, and Youth (Part D) Other Programs (Part F) Dental, Education/Training, Planning, Capacity Development and Demonstrations, Minority AIDS Initiative

11. Ryan White HIV/AIDS Program: Part A Provides emergency assistance to Eligible Metropolitan Areas (EMAs) and Transitional Grant Areas (TGAs) that are most severely impacted by the HIV/AIDS epidemic EMAs have at least 50,000 inhabitants and >2,000 reported AIDS cases in the past 5 years TGAs have at least 50,000 inhabitants and 1,000-1,999 reported AIDS cases in the past 5 years or prior status as an EMA Award made to Chief Elected Official Funding allocations determined by Planning Council Part A funds distribution: 2/3 by formula – based on the number of living cases of HIV (non-AIDS) and AIDS 1/3 supplemental – competitive grand process

12. Current EMAs (N=24) Atlanta, GA Baltimore, MD Boston, MA Chicago, IL Dallas, TX Detroit, MI Ft. Lauderdale, FL Houston, TX Los Angeles, CA Miami, FL Nassau-Suffolk, NY New Haven, CT New Orleans, LA New York, NY Newark, NJ Orlando, FL Philadelphia, PA Phoenix, AZ San Diego, CA San Francisco, CA San Juan, PR Tampa-St. Petersburg, FL Washington, DC West Palm Beach, FL

13. Current TGAs (N=29) Austin, TX Baton Rouge, LA Bergen-Passaic, NJ Charlotte-Gastonia, NC-SC Cleveland, OH Columbus, OH Denver, CO Ft. Worth, TX Hartford, CT Indianapolis, IN Jacksonville, FL Jersey City, NJ Kansas City, MO Las Vegas, NV Memphis, TN Middlesex-Somerset-Hunterdon, NJ Minneapolis-St. Paul, M Nashville, TN Norfolk, VA Oakland, CA Orange County, CA Ponce, PR Portland, OR Riverside-San Bernardino, CA Sacramento, CA Saint Louis, MO San Antonio, TX San Jose, CA Seattle, WA

14. 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

15. Components/Entities in Part A Structure • Chief Elected Official – Official recipient of Part A funds (mayor, county executive, chair county board of supervisors, freeholder, judge, etc.) • Grantee – Administering agent for Part A funds • Administrative or Fiscal Agent – Assists in fulfilling administrative activities • Planning Council – Establishes plans and priorities for the area

16. Federal Government CEO of Designated EMA/TGA Administrative Agent or “Grantee” (Often the Health Department) • HIV Services Planning Council*(Mandated membership categories) • Sets Part A service priorities and allocates grant funds • Develops service plan • Assesses grantee efficiency in disbursing grant funds. Providers (Public & private nonprofitcommunity- based organizations) Services are provided tolow-income & uninsured people living with HIV/AIDSand their families Flow of Part A Funds and Decision Making (*Council not required for new TGAs)

17. 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

18. Grantee and Planning Council Roles and Responsibilities

19. 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

20. Interpreting the Needs Assessment:Putting the Pieces Together

21. 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

22. Priority Setting • Planning Council responsibility • Means determining what service categories are most important for PLWH in the EMA\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

23. 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, and decrease

24. Directives • Planning Council responsibility • 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’s directives in procurement and contracting (but cannot always guarantee full success)

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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?

32. Applying Knowledge At its most recent Town Hall meeting to hear about PLWHA 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?

33. Applying Knowledge In its ongoing monitoring of service providers, the grantee hears from one of its primary care providers about the need for and his or her interest in establishing a new mobile dental service. The grantee has documented a chunk of unexpended funds across its providers; should the grantee supplement the existing contract of this provider?

34. Applying Knowledge Halfway through the current grant year, and through its ongoing contract monitoring, the grantee learns that the 4 major outpatient/ambulatory care providers estimate that approximately 20% of their current clients will be eligible for new ACA Medicaid expansion in 2014. What should the grantee do with this information? • Applying Knowledge

35. 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 in the most recent calendar year as confirmed by CDC • 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%) • Minority AIDS Initiative funding is calculated based upon the number of living minority cases of HIV/AIDS cases in the EMA/TGA in the most recent calendar year as confirmed by CDC. Minority AIDS Initiative funding is used to address disparities in access and retention in care and improve health outcomes for racial and ethnic minorities

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

37. 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 Part A program guidances • Up to 25% of service funds may be spent on support services that contribute to positive clinical outcomes

38. 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 • Medical case management including treatment adherence • Health insurance premium & cost sharing assistance • Home health care • Home and community-based health services • Medical nutrition therapy • Hospice services

39. 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* Ryan White Part A and Part B Support Services

40. Support Services • Must be: • ≤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

41. 2. Focus on Getting People into Care • Unmet need = need for primary health care among PLWHA who know they are HIV+ and 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

42. 3. Limits on Non-Service Funding • Focus: maximize funding for direct services • 2006 legislation has a 10% administrative cap inclusive of planning, evaluation, and Planning Council support • Another 5% (or $3 million, whichever is less) for Clinical Quality Management – assess quality of care and clinical outcomes

43. 4. “Use or Lose” Formula Funding • Penalty for unobligated and 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

44. 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

45. Ryan White HIV/AIDS Program Challenges Increased demand for services in an environment of few new/declining resources Rising costs Growing HIV/AIDS prevalence Increasing financial pressure on medical systems Earlier HIV treatment per DHHS Treatment Guidelines Chronicity of HIV disease/aging More comorbidities (including viral hepatitis) Increased need for primary care Identifying HIV infection earlier Expanding HIV testing Improving linkage to and retention in care Supporting the HIV workforce Need for both primary care and specialty services

46. 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

47. Reduce new infections (25%), lower transmission rate (30%), and increase to 90% awareness of HIV+ serostatus Improve access to and outcomes of care by linking 80% of PLWH to care within 3 months of diagnosis, increase to 80% of Ryan White clients in continuous care, and increase to 86% of Ryan White clients with permanent housing Reduce HIV-related health disparities by increasing by 20% the number of diagnosed men who have sex with men (MSM), blacks, and Latinos with undetectable viral load National HIV/AIDS Strategy: Targets for 2015

48. Network Adequacy Will the number, distribution, and types of providers be sufficient? To what extent will Ryan White funded providers be included in the networks of plans offered in the new Health Insurance Exchanges? Is the onus on providers to make their case to contract with Medicaid managed care or the HIEs, or will there be expectations on the plans? Continuity & Quality of Care – will individuals living with HIV/AIDS have to change providers and will the quality of care be at the same high level as that provided via Ryan White funding? State flexibility/variation in implementation – “Be at the Table” The Patient Protection and Affordable Care Act – Challenges from an HIV Perspective

49. HIV/AIDS Bureau : DMHAP Expectations Legislation National HIV/AIDS Strategy National Factors-ACA, Funding Treatment Paradigm • How priority issues emerge

50. 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