Alternate Payment Models for Ryan White HIV/AIDS Program Funded Services: Strategies Used by Nine Grantees Prepared for the District of Columbia HIV/AIDS, Hepatitis, STD and TB Administration Naomi Seiler, JD Scott Dafflitto, JD, MPH Rosalind Fennell Julia Hidalgo, ScD, MSW, MPH Katie Horton, RN, MPH, JD Mary-Beth Malcarney, JD, MPH The George Washington University Milken Institute School of Public Health Department of Health Policy and Management March 24, 2015 Contents ACKNOWLEDGEMENTS ......................................................................................................... 2 INTRODUCTION......................................................................................................................... 3 METHODOLOGY ....................................................................................................................... 5 KEY FINDINGS ........................................................................................................................... 7 RWHAP Service Categories Included in Payment Models ................................................... 7 Fee Setting .................................................................................................................................. 7 Staffing and Data Systems ...................................................................................................... 10 Benefits and Challenges in Implementing Alternative Payment Models ........................... 12 CONCLUSION ........................................................................................................................... 15 GRANTEE PROFILES .............................................................................................................. 16 Fort Lauderdale/Broward County ........................................................................................ 16 Los Angeles County ................................................................................................................. 17 Miami-Dade ............................................................................................................................. 20 New York City ......................................................................................................................... 23 Orange County ........................................................................................................................ 27 San Diego .................................................................................................................................. 28 St. Louis .................................................................................................................................... 29 New York State ........................................................................................................................ 30 Washington State .................................................................................................................... 32 APPENDICES ............................................................................................................................. 34 APPENDIX 1: LA COUNTY: FEE-FOR-SERVICE AND ADDITIONAL REIMBURSEMENT INCENTIVES GUIDELINES APPENDIX 2: LA COUNTY: MERCER, MEDICAL CLINICAL FEE-FOR-SERVICE REIMBURSEMENT RATE STUDY (2008) APPENDIX 3: MIAMI-DADE COUNTY: COST AND ELIGIBILITY SUMMARY (2014) APPENDIX 4: NEW YORK CITY: PERFORMANCE-BASED REIMBURSEMENT APPENDIX 5: NEW YORK CITY: REIMBURSEMENT PLAN FOR RYAN WHITE CARE COORDINATION (2012) 1 Acknowledgements The authors would like to thank the following individuals who shared their time and expertise to explain their respective jurisdictions’ approaches to payment in the Ryan White program: Ft. Lauderdale/ Broward County: Leonard Jones, Manager of the Ryan White Part A Program Los Angeles County: Mario Perez, Director of the County of Los Angeles, Division of HIV and STD Programs Kyle Baker, Chief of Staff and Director of Government Relations, Division of HIV and STD Programs Tara McMackin, Executive Secretary, Division of HIV and STD Programs Miami-Dade County: Carla Valle-Schwenk, Program Administrator, Miami-Dade County Office of Management and Budget, Grants Coordination/Ryan White Program New York City: Amber Casey, Ryan White Grant Administrator, Care and Treatment Program, Bureau of HIV/AIDS Prevention and Control Graham Harriman, Interim Director Care and Treatment, Bureau of HIV/AIDS Prevention and Control Rachel Miller, Vice President for HIV Programs and Special Initiatives, Public Health Solutions Gucci Kaloo, Director of Finance and Operations, Public Health Solutions Orange County: Tamarra Jones, HIV Planning and Coordination Manager, Health Care Agency San Diego County: Patrick Loose, Chief, HIV, STD and Hepatitis Branch of Public Health Services St. Louis: Megan Lengerman, Medical Services Coordinator/Regional Case Management Supervisor, City of St. Louis New York State: Mona Scully, Health Care and Policy Deputy Director, AIDS Institute Christine Rivera, Director of HIV Uninsured Care Programs John Fuller, Director of Grants Management Washington State: Richard Aleshire, HIV Client Services Program Manager Karen Robinson, Medical Case Management and Community Programs Supervisor Any errors or omissions are the responsibilities of the authors. Introduction The Health Resources and Services Administration (HRSA) HIV/AIDS Bureau (HAB) offers Ryan White HIV/AIDS Program (RWHAP) Part A and Part B grantees some flexibility in determining the method used for paying subgrantees for core medical and support services. Many Part A and Part B grantees use a traditional “cost-based reimbursement” approach, in which subgrantees submit budgets that include personnel costs, other direct costs related to the provision of funded services, and capped indirect costs (IDCs). Some grantees, however, have developed alternative reimbursement models for core medical and/or support services. This report summarizes the reimbursement approaches taken by nine RWHAP grantees. While not an exhaustive list, the seven Part A and two Part B grantees demonstrate a range of payment methods that might provide ideas for other grantees. This report utilizes the following terms to describe various reimbursement concepts: 3 Cost-based reimbursement and full-time equivalent (FTE) coverage: Generally defined as paying allowable costs incurred, up to a set limit. Most grantee staff interviewed use “cost-based reimbursement” to refer to the “traditional” reimbursement model of paying for line item personnel costs, including FTEs, as well as other direct costs. Fee-for-service (FFS): A FFS approach involves paying a specific, agreed-upon amount for each unit of service provided. As discussed in greater detail below, the fees may be set by the grantee, negotiated based on accounting data provided by subgrantees, or benchmarked using other fee schedules such as Medicaid or Medicare. Unit cost reimbursement: Unit cost reimbursement can be considered a type of FFS, in that payment is made for each “unit” of service provided. The units are clearly defined (e.g., an x-ray conducted during a dental visit, a 15-minute unit of a face-to-face medical case manager visit, a bag of food, or a mile driven for medical transportation); and the “unit cost” is the aggregate cost of inputs associated with providing a given unit of service. The cost may be calculated by dividing all subgrantee costs by the number of units provided. A grantee could choose to calculate a standard unit cost based on the average costs of inputs across subgrantees; build on benchmark unit cost payment systems used by Medicaid or Medicare; or apply a blended approach. Performance-based payment: Also sometimes known as “pay for performance” (P4P), performance-based systems are based on a requirement that subgrantees meet certain standards set prior to the contract period. While several grantees reported using “performance-based” payments to describe a broad range of payment models, it appears that of the interviewees, only LA County has already implemented a system with payments that are linked to subgrantee performance. 4 In general, there are two ways a Ryan White grantee could implement performance-based payments: In one model, grantees could set aside a percentage of funds allocated to that service category (a “withhold”) throughout the grant year. At the end of the grant year, grantees would then distribute the withheld funds across subgrantees that met performance benchmarks. Alternatively, grantees could adjust future payment rates based on past year performance. Either way, payment levels would be linked to meeting certain performance criteria. Enhanced payment could be based on meeting certain thresholds for performance (e.g., testing at least X% of clients for TB in a given year) or could be scaled based on how well a subgrantee performs beyond the threshold level. In theory, a Ryan White grantee could also base performance-based payments on patient outcomes, such as a certain percentage of clients having undetectable viral load. It is important to note that GW staff found in our assessment that grantees applied different terms for the payment models that are used. Therefore, throughout this report we attempt to make clear both what a grantee defines as its payment system and how the system is actually operationalized. Because HAB refers to the recipients of grantee funding as subgrantees, that term is used throughout this report, even where providers are technically not subgrantees but contractors.