# Presentation: 696766

## Impact of 2006 Ryan White HIV/AIDS Treatment Modernization Act on the New York Eligible Metropolitan Area

- Monica Sweeney, MD, MPH
- Assistant Commissioner
- Bureau of HIV/AIDS Prevention and Control

- President’s Advisory Council on HIV/AIDS
- October 21, 2008

## Presentation Outline	

- Epidemiologic Background
- Ryan White Part A in NY EMA
- Impact of 2006 Ryan White HIV/AIDS Treatment Modernization Act
- 2009 Reauthorization and Beyond
- NYC DOHMH HIV/AIDS Initiatives
- Questions and Answers

## Epidemiologic Background

## Efficacy of HIV/AIDS Treatment

- Projected lifetime cost per person at the time of entering optimal HIV care is **$385K**, and the treatment expense that can be avoided by preventing each HIV infection is **$303K**1
- Increasing HIV prevention funding to **$1.3B** a year over next 4 years could reduce the number of new HIV infection by 50%2

- 1 Schackman BR et al. The lifetime cost of current human immunodeficiency virus care in the United States. *Med Care* 2006 Nov; 44:990-7
- 2 U.S. House. Committee on Oversight and Government Reform. *The Domestic Epidemic is Worse than We Thought: A Wake-Up Call for HIV Prevention: Hearing before the Committee on Oversight and Government Reform of the House of Representatives.* 110th Cong., 1st sess., 16 September 2008. Washington, D.C.: G.P.O., 2008.

## Cost per New Positive DiagnosedCommunities of Color Contracts (2006)

| Testing Venue | Cost per New Positive Diagnosed |
| --- | --- |
| Community-based Organizations (CBO) | $11,660 |
| Private Hospitals | $10,014 |
| Public Hospitals | $6,641 |
| WEIGHTED AVERAGE | $8,376 |

## Ryan White Part A Program in NY Eligible Metropolitan Area (EMA)

## Overview: NY EMA Administration

- The New York City Department of Health and Mental Hygiene (NYC DOHMH) oversees the Ryan White Part A and MAI grants
- HIV Care, Treatment, and Housing Program
- Public Health Practice/Research and Evaluation
- Policy, Planning and Implementation
- Housing Services
- Ryan White Services
- Ryan White Planning Council Support
- Contracts with:
- Public Health Solutions for contract administration
- Westchester County Department of Health for the Tri-County region (Westchester, Rockland, Putnam Counties)

## Overview: NY EMA Funding

- 2008 Minority AIDS Initiative and Base grant award is $118.8 million
- 251 contracts with 128 unique agencies
- Service categories funded:

-  _**Core Services (76%)**_
-  Outpatient medical care
- ADAP/ADAP+
- Oral Health Care
- Early intervention services
- Home Care
- Mental health
-  Medical case management, maintenance in care & treatment adherence
-  Harm reduction (substance abuse)
- Transitional support for incarcerated individuals

- 	 _**Support Services (24%)**_
-  Food and nutrition
-  Legal services
-  Supportive counseling and family stabilization (psychosocial support)
-  Medical transportation
- Housing placement
- Emergency transitional housing and rental assistance

## NY EMA Part A Funding

## Impact of 2006 Ryan White HIV/AIDS TreatmentModernization Act

## Part A Tier 1 Formula	

- With new legislation, in name-based areas (such as New York City and State) living HIV/AIDS cases reported and confirmed by the CDC are used for formula grant
- More HIV and AIDS cases counted, yet total level of funding remained unchanged

## Varying Award Amounts

- As shown in earlier slides, NY EMA award has fluctuated over the past several years
- Variances in award amounts make it difficult to plan and implement services
- With city and state budget crises, hiring freezes are a reality, which cause a lack of staff to execute work

## Distribution of Funds

- Part A distribution of funds changed during last reauthorization from:
- 50% formula; 50% supplemental
- to
-  67% formula, 33% supplemental
- Large, urban EMAs like NY have high unmet needs due to mature HIV/AIDS population this change limits local control
- High housing/health care costs, low educational levels, high poverty levels, large immigrant populations, language and social barriers
- NYC HHC public hospital system treat and care for patients who speak over 100 different languages, which reflect the diversity of NYC

## Underspending Limit

- Excessive Formula underspending results in inability to apply for future Supplemental
- With 251 contracts in 128 unique agencies, this is a challenging task
- In 2005, NYC DOHMH decided to pursue performance-based contracting under a new model. The plan included transitioning the portfolio by 2010
- Must routinely and closely monitor spending and spend Part A funds expeditiously

## Distribution of Core/Non-Core Services

- 75% (core/medical)/ 25% (non-core)
- 75% of funds under each title must be spent on Core Medical Services. The remaining 25% may be used for support services needed to achieve medical outcomes*
- EMA portfolio has evolved over time and there has been a commitment to funding core services

- *Medical outcome is defined as those outcomes affecting the HIV-related clinical status of an individual with HIV/AIDS.

## Base and MAI Coordination

- Formula awards made in March
- Supplemental awards made in May (only in 2007)
- MAI awards made in August
- Different award cycles make it very difficult to effectively and efficiently plan services across the EMA

## Medical Case Management

**Tri-County**
- $2.1 million allocated (42% of award)
- $160,000 average budget
- 13 new programs: 8 Article 28s, 5 CBOs
- Monthly meetings of all case managers to promote better coordination and communication
- Quarterly quality management learning network meetings

**NYC**
- Treatment Adherence since 1998
- Maintenance-In-Care since 2007
- Quarterly quality management learning network meetings
- Complete services (including Treatment Adherence, Health Promotion, entitlement support) in 2009 (in development since 2007)

## HIV Testing and Prevention

- HIV prevention and testing are important to all parties—NYC DOHMH, NY State, HRSA, CDC, etc
- Part A Early Intervention Services make HIV testing and linkages to care possible
- Confirmatory testing not included
- HRSA guidance on providing Ryan White services to HIV negative clients makes it difficult to support

## 

2009 Reauthorization and Beyond 

**2009 Reauthorization and Beyond**

## The Future of Ryan White:More Money is Needed!

| Program | President’s FY 2009 Request | House Labor/HHS Subcommittee Mark-up | Senate Labor/
Subcommittee Mark-up |
| --- | --- | --- | --- |
| Part A | $619.4 
(-$7.7m) | $670.0m (+$42.8m) | $619.4m 
(-$7.7m) |
| Part B Base | $409.1m (+$8.2m) | $415.4m (+$14.5m) | $409.1m (+$8.2m) |
| Part B ADAP | $800.4m 
(+$6m) | $822.7m (+$28.3m) | $800.4m (+$6m) |
| Part C | $198.8m 
(+0) | $205.0m (+$6.2m) | $198.8m 
(+0) |
| Part D | $73.7m 
(+0) | $80.0m (+$6.3m) | $73.7m 
(+0) |
| Part F AETC | $28.7m 
(-$5.4m) | $34.7m (+$0.6m) | $34.1m 
(+0) |
| Part F Dental Reimb. | $12.9m 
($0) | $14.0m (+1.1m) | $12.9m
(+0) |

## What’s Important for NY

- Emerging priority populations and newly released HIV incidence figures necessitate increased Ryan White HATMA funding
- Length of Ryan White HATMA reauthorization
- 24 month housing limit
- Coordination with other federal programs like CDC, SAMSHA
- Continuity of care- gap in care for those Ryan White clients who need inpatient and ancillary services

## DOHMH Bureau of HIV/AIDS Prevention and Control Initiatives

## Care Coordination* - Background

- Ensure that persons with HIV/AIDS are linked to and retained in regular care and that treatment adherence is supported
- With today’s therapeutic options, HIV viral suppression is achievable even with multi-drug resistance
- Medical case management can be an effective means of linking  patients to care, reducing barriers, and improving health outcomes
- Relatively costly adherence interventions – directly observed therapy (DOT) at $500/month - are cost-effective

- *Care Coordination = medical case management

## Care Coordination – Initiative Details

- Almost $27M – 1⁄4 of the Part A award - budgeted for 2009
- Incorporation of the medical home principle* and use of information technology to strengthen collaboration across disciplines
- Hybrid model includes navigation-type case management, benefits coordination, health promotion, DOT and outreach for return to care

- model  for  care  provided  by  physician  practices  that  seeks  to  strengthen  the  physician-patient  relationship  by  replacing  episodic  care  based  on  illnesses  and  patient  complaints
- with  coordinated  care  and  a  long-term  healing  relationship.

## Field Services Unit (FSU)

_**FSU founded in 2006 to improve partner notification**_
- In 2007, DOHMH notified 10 x more partners than non-DOHMH reporting facilities
- Partner investigations are time intensive and require skilled interviewers
_**FSU piloted Out of Care program starting in fall 2007:**_
- To assist hospitals in returning patients who were lost to care for > 6 months and to conduct partner investigations for these patients
- hospital’s own clinical and case management staff were unable to locate patient
- Initiated program in Brookdale Hospital
- Expanding in fall 2008 to Lincoln Hospital

## FSU Partner Notification Process

| Cases interviewed | Partners notified | Partners previously positive | Partners newly positive |
| --- | --- | --- | --- |
| 1714 | 675 | 231 | 44 |

**Field Services Unit, NYC Dept of Health, Cumulative Data**

***** 54 tested for the first time in their lives*** **

- Interview
- with
- HIV+ person

- Partner
- elicitation

- Partner
- notification

- Offered HIV
- testing

- New HIV+
- Partner
- linked to
- care

**PN Data July 2006-March 2008**

## DOHMH HIV Testing Programs

**Objective: Every New Yorker learns his or her HIV status and has access to quality care and prevention**

## 

 Questions and Answers

-  Questions and Answers