Setting Priorities in Developing Budgets

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Setting Priorities in Developing Budgets

• Ryan White All Titles Conference
• Eli Camhi, MSSW
• ecamhi_at_generes.com

http//homepage.mac.com/ecamhi/Exchange/
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Session Focus

• Maintaining HIV programs while patient loads are
  increasing and grant funding levels are not.

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Session Goal

• Developing an overall HIV program with multiple
  funding streams rather than a Title- specific
  programs
• Prioritizing budgets based on program
  expectations
• Collaborating with other CARE Act Titles and
  other providers to extend capabilities
• Managing increasing patient loads when funding
  does not support additional staff.

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Session Outcome

• Participants will be able to
• describe the required and optional services for
  each program,
• identify potential partners, and
• identify strategies for dealing with increased
  caseloads

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Guidance and Legislative Requirements

• 10 of Budget Administrative Cap
• 50 of Budget Primary Care (Title III)
• Must not supplant existing funding
• Payer of Last Resort
• Maximize 3rd Party Reimbursement
• Cap on Charges and Sliding Fee Scale

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Title III Required Services

• HIV counseling, testing, referral, and partner
  counseling services.
• Medical evaluation and clinical care
• CD4 cell monitoring, viral load testing,
  antiretroviral therapy, prophylaxis and treatment
  of opportunistic infections, malignancies and
  other related conditions, routine immunizations,
  prevention of perinatal transmission, and patient
  education including linkage to prevention
  services.
• Other primary care medical services provided
  either directly or through a formal referral
  mechanism
• including oral health care, adherence counseling,
  outpatient mental health care, outpatient
  substance abuse treatment, nutritional services,
  and specialty medical care.
• Prevent new infections by working with persons
  diagnosed with HIV and their partners

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Title III Required Services

• HIV counseling, testing, referral, and partner
  counseling services.
• Medical evaluation and clinical care
• Other primary care medical services provided
  either directly or through a formal referral
  mechanism
• Prevent new infections by working with persons
  diagnosed with HIV and their partners

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Title III Optional Services

• Outreach to
• those who may be at high risk of contracting the
  disease and need referral for counseling and
  testing
• those who may have HIV disease in order to
  explain the benefits of early intervention and
  link them into care and
• providers to make them aware of the availability
  and benefits of EIS/primary care.
• Eligibility Assistance to individuals in
  establishing eligibility for financial support
  and services under Federal, state, or local
  programs providing health services, mental health
  services, social services, or other appropriate
  services.
• Case Management to persons infected with HIV
  including referrals for appropriate social
  support services.

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Title IV Expectations

• Develop, expand, and support a comprehensive,
  coordinated, culturally competent,
  family-centered system of HIV care.
• Educate clients about research and research
  opportunities. Programs are expected to link
  clients to appropriate research and use
  supportive services to make research accessible.
• Involve consumers as partners in their own care.
  
• Recruit and retain women in care. For women of
  child bearing age, this includes preventing
  transmission of HIV from mother to infant.
• Find individuals who are infected but not
  receiving primary medical care, or who are at
  high risk of infection.

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Possible Changes in Reauthorization

• Core Medical Services
• including outpatient and ambulatory health
  services medications oral health care early
  intervention services health insurance premium
  and cost sharing assistance for low income
  individuals home health care home and
  community-based health services except homemaker
  services hospice services mental health
  services substance abuse outpatient care and
  medical case management (including treatment
  adherence service).
• Title I-III At least 75 must be spent on Core
  Medical Services

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Purpose of Funding

• Ryan White Comprehensive AIDS
• Resources Emergency (CARE) Act
• Early Intervention
• Access to Primary Care and Antiretroviral Therapy

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Multiple Funding Streams

• Ryan White Titles
• Organizational In-Kind
• Third Party Reimbursement
• Medicaid
• Medicare
• Private Insurance
• Self Pay
• Other

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Federal Spending on HIV/AIDS

• despite national treatment guidelines calling for
  early access to medical care and treatment
• approximately 42 to 59 of the almost one
  million people living with HIV/AIDS are not in
  regular care
• Up to 1/3 may not know their status
• Programs vary by state

Total 11.0 Billion
Sources KFF, Trends in U.S. Government Funding
in HIV/AIDS Fiscal Years 1981 to 2004, March
2004 Medicaid and Medicare estimates from CMS,
Office of the Actuary 2004 and HHS Office of
Budget, 2004.
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Ryan White CARE Act
Side by Side Comparison of the Law Current
Proposals www.kkf.org
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Reauthorization Proposed Changes

• Core Medical Services
• including outpatient and ambulatory health
  services medications oral health care early
  intervention services health insurance premium
  and cost sharing assistance for low income
  individuals home health care home and
  community-based health services except homemaker
  services hospice services mental health
  services substance abuse outpatient care and
  medical case management (including treatment
  adherence service).
• Title I-III At least 75 must be spent on Core
  Medical Services

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Staying Informed

• The Care of HIV-Infected Adults in the United
  States - Bozzette
• Public Financing and Delivery of HIV/AIDS Care
  Securing the Legacy of Ryan White - Institute of
  Medicine
• Financing HIV/AIDS Care A Quilt with Many Holes
  - Kaiser Family Foundation

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Know Your Budget

• Personnel
• Other Than Personnel
• Contracts
• Administrative

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Key Decision Makers

• Who wrote the application
• Who approves the budget
• Who manages the program
• Do you participate

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Mind Tools a resource

• Decision Making Techniques
• Grid Analysis
• http//www.mindtools.com/pages/article/newTED_03.h
  tm
• Cost/Benefit Analysis
• http//www.mindtools.com/pages/article/newTED_08.
  htm

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Grid Analysis Example
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The Budget Process

• Establish Budget
• Monitor Expenditures
• Variance Reports
• Strategic Planning
• Budget Modification

Variance
Planning
Budget Mod
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Monitoring Budgets

• Variances
• Startup
• Vacancies
• Budget Modifications

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Personnel

• Primary Care Provider
• Case Managers
• Adherence Counselors
• Counseling and Testing Staff
• Nursing and Phlebotomy
• Quality Improvement Staff

• Referral Coordinator
• Administrative and Clerical Staff
• Pharmacist
• Data Management
• Mental Health and Specialty Providers
• Dental Services Staff
• Volunteer Coordinator

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Other Than Personnel

• Medication
• Supplies
• Equipment
• Laboratory Tests
• Transportation
• Rapid Tests OraSure

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Contracts

• Laboratory
• Transportation
• Primary Care
• Case Management
• Specialty Care
• Ancillary
• Home Care
• Radiology

• Pharmacy
• Dental
• Testing
• Outreach

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Anticipating Problems

• Vacancies
• Leaves and Resignations
• Organizational Pressure
• Under Spending

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Anticipating Success

• Increased Demand
• Rapid Testing ? Primary Care
• ARV Treatment ? Living with HIV
• Living with HIV ? At risk non-HIV related disease
• Heart Disease
• Cancer
• Diabetes
• HIV and Over 50
• Discovering New Gaps in Service

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Leveraging Resources

• Building the Care Continuum
• Partnering with Grantees
• List at http//hab.hrsa.gov
• Identifying Capacity
• Sharing the Care
• Identifying and Supporting Income Generating Staff

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Promoting Client Autonomy

• Give a man or woman a fish, s/he eats for a day.
• Teach a man or woman to fish, s/he eats for the
  rest of her/his life.

We succeed when our clients need us less!