ACA Change Options for a Standalone HIV Organization

Guide for Board of Directors Considering Changes to Adjust to the Affordable Care Act

Developed by Catawba Care for a Board Retreat, 2013

Overview/Purpose

The Affordable Care Act is expanding insurance coverage options and exploring service delivery innovations to improve care and manage costs. These changes are placing new demands on agencies to develop the capacity to both operate within an expanded third party payer environment and deliver services in new ways.

Many agencies funded by the Ryan White HIV/AIDS Program can benefit from undertaking an internal review of their infrastructure and readiness to adjust to change. One key step is for the agency’s leaders—particularly the board of directors—to consider various needs and options. The below tool outlines various restructuring options for the board of directors of a stand-alone HIV/AIDS organization to consider in adjusting to the Affordable Care Act. The tool was developed by Catawba Care in South Carolina and was used to guide the agency’s decision-making on how to adjust to health care reform.

Using the Tool

The following pages present options for an HIV/AIDS agency’s board to consider. Each option outlines the implications of the option, the objective, and additional considerations (e.g., services, revenue necessary). In using the tool:

· Discuss. The board should discuss each option in an open-ended manner.

· Process. Ideally, the options can be discussed over several board meetings. The discussion can be led by the Executive Director or a trained facilitator.

· Decision Points. The board does not need to decide on a particular option to pursue and can use this tool to simply get the conversation going. Decisions may even be best deferred by collecting more concrete assessment data or reviewing existing reports. If a vote is taken, options include consensus, a vote on all seven options, prioritize the top three and then vote.

Options

Option 1: Remain As Is: Stand-Alone HIV Organization

Option 2: Provide HIV Wrap-around Services Only (non-primary care services)

Option 3: Become a Community Health Center

Option 4: Become Primary Care Provider & Seek Look-Alike Status

Option 5: Collaborate with CHC (could be in combination with Scenario #1)

Option 6: Free Clinic: Consider Merger with CHC or Become Independent Free Clinic

Option 7: Merge with Community Health Center

Option 8: Plan for Closure and Transfer Patients to Other Providers

Chart: Pros and Cons of Option __:

Option 1: Remain As Is: Stand-Alone HIV Organization

1 – ACA Change Options for a Standalone HIV Organization – Catawba Care – 2013 – http://careacttarget.org

Implications
If we could maintain 340B funding, could do with less Ryan White funding and make up funds with private dollars. If we lose Ryan White funding and 340B funding, we would need means of replacing this revenue. Could increase billing revenue if more strategic with scheduling and increased emphasis on productivity. May not be able to provide as much service, depending on replacement revenue. Would need to focus much more on fundraising.
Objective
To ensure people living with HIV/AIDS have access to primary and infectious disease care and to provide as much supportive and prevention services as we can given funding limitations.
Primary Service Population
Those living with HIV and those at risk for HIV.
Services, Treatment and Care That Would be Provided
Depending on ability to maintain funding, HIV-specific services only.
Organizational Structure
Same as now.
Funding Source(s) Available and/or Needing Development
Increased program income from medical billing; increased private support; maintenance of 340B and/or portion of Ryan White funding.

Option 2: Provide HIV Wrap-around Services Only (non-primary care services)

Implications
HIV+ clients would get primary medical care at the community health center or out of service area. Could include HIV specialty care if had payment source for this (payments from community health center, insurance/Medicaid/Medicare). If not prescribing medications, would not have 340B drug program.
Objective
To ensure people living with HIV/AIDS have access to primary and ID care and to provide as much supportive and prevention services as we can given funding limitations.
Primary Service Population
Persons living with HIV and those at risk for HIV Services, treatment and care provided.
Services, Treatment and Care That Would be Provided
HIV specialty medical care, case management, supportive services as fundable, HIV testing and prevention as fundable.
Organizational Structure
Policy and Oversight: Board and Management
Administrative and Operational: Less clinical staff; probably outsourced medical billing since only infectious diseases care
Funding Source(s) Available and/or Needing Development
Assumes Ryan White funding continues to support wrap-around services; increased private funding; anticipate less 340B if not offering primary care due to ADAP taking proceeds from HIV medications for privately insured and Medicare eligible. Possible continuation of 340B for Medicaid Managed Care HIV medications.

Option 3: Become a Community Health Center

Implications
Change of mission; would need to serve significantly more patients and increase current productivity of providers; would need to expand building. Could only offer a service if available to all patients with CHC funds. Requires change in Board composition (more than 50% patients of CHC). Would be able to maintain and grow 340B program, and receive enhanced reimbursements and government malpractice coverage. Possible competition with current CHC. In order to become CHC, would require approval and funding from HRSA. Would require change to sliding fee scale.
Objective
To ensure continuity of care for people living with HIV/AIDS while also expanding services to others in need in our community, given our expertise in delivery of these type services and the anticipated reduction in Ryan White funding for HIV-only services.
Primary Service Population
[Designated project area] with a focus on those who are uninsured, low-income, under-insured, have Medicaid, needing a medical home for primary care. This would include continued service to people living with HIV, including HIV specialty care.
Services, Treatment and Care That Would be Provided
Services would need to be provided for all patients equally, regardless of HIV status unless funded through a different grant source (Ryan White funding) from community health center funding. This could mean, especially if Ryan White funding is reduced/ eliminated, that patients would receive fewer services (less specialty care off-site, no reduction in cost of care for those over 200% of Federal Poverty Level, and fewer supportive services unless offered to all health center patients or completely funded from other funds).
Organizational Structure
Policy and Oversight: Board of Directors made up of CHC patients (could be current Board members if they became patients of the CHC) and with diversity representative of patient population.
Administrative and Operational: Would need additional administrative staff and additional clinical staff; prevention and case management staff would most likely need to be funded (at least partially) with other funding.
Funding Source(s) Available and/or Needing Development
Initial CHC grant is around $600,000; 340B funding would most likely increase with more patients, but the revenue on primary care medications is not as significant as on HIV medications. Additional CHC grant opportunities become available once approved for initial funding. Medical billing would need to increase (increased staff with more knowledge and experience) as well as clinician productivity (more clinicians seeing many more patients each day than currently occurs). Grants, fundraising can also continue with CHC although many CHC’s operate primarily on program revenue & federal funding.

Option 4: Become Primary Care Provider Seek Look-Alike Status

Implications
Would change our mission; would be serving more patients; would need to expand building. Could only offer a service if available to all patients. Would require change in Board composition (more than 50% patients of CHC). Would not receive funding from HRSA but could get benefits (340B, malpractice, enhanced reimbursement). In order to become CHC look-alike, would require becoming primary care provider and receiving approval from HRSA. Is not competitive grant since no funding is attached. Would require change to sliding fee scale.
Objective
To increase ability to generate revenue through enhanced reimbursement and 340B if Ryan White funding is eliminated, in order to ensure continuity of care for people living with HIV/AIDS while also expanding services to others in need in our community, given our expertise in delivery of these type services.
Primary Service Population
[Designated project area] with a focus on those who are uninsured, low-income, under-insured, have Medicaid, needing a medical home for primary care. This would include continued service to people living with HIV/AIDS, including HIV specialty care.
Services, Treatment and Care That Would be Provided
These fall under the same requirements as being a CHC; services must be open for all, but no funding comes with this designation. Our services delivered would be dependent on our funding streams and priorities.
Organizational Structure
Policy and Oversight: Board of Directors made up of clinic patients (could be current Board members if they became patients of the CHC) and with diversity representative of patient population.
Administrative and Operational: Would need additional administrative staff and additional clinical staff to provide primary care for broader population unless we capped it at lower number.
Funding Source(s) Available and/or Needing Development
Would be eligible for same enhanced reimbursement from Medicaid and Medicare as with CHC; would be able to maintain 340B; would need to enhance medical billing and identify private funding in order to provide more services. Would potentially be more likely to receive CHC funding in future if already approved as Look-Alike status (but not guaranteed).

Option 5: Collaborate with CHC (could be in combination with Scenario #1)

Implications
Agree to provide infectious disease care for CHC patients at negotiated rates (not enhanced rates); could most likely maintain 340B if maintain some level of federal funding. May do less primary care, no primary care, or continue primary care for those not going to CHC if we could fund this through medical billing/ private sources (if Ryan White funds for primary care are removed).
Objective
To ensure people living with HIV/AIDS have access to primary and infectious disease care and to provide as much supportive and prevention services as we can given funding limitations.
Primary Service Population
HIV positive population.
Services, Treatment and Care That Would be Provided
Could continue to provide infectious disease care and wrap-around services but allow CHC to provide primary care. Services dependent on ability to raise funds for services, whether federal (Ryan White) or private. Would most likely not do specialty care outside of HIV.
Organizational Structure
Policy and Oversight: Current Board of Directors structure; contracts with CHC for collaborations.
Administrative and Operational: Potential reduction in clinical staff if not providing primary care. Probably need to outsource medical billing to be more cost effective.
Funding Source(s) Available and/or Needing Development
Assumes Ryan White funding continues to support wrap-around services; increased private funding; anticipate less 340B if not offering primary care due to ADAP taking proceeds from HIV medications for privately insured and Medicare eligible. Possible continuation of 340B for Medicaid Managed Care HIV medications. CHC enhanced reimbursements would not be passed on to agency for infectious disease care.

Option 6: Free Clinic: Consider Merger with CHC or Become Independent Free Clinic

Implications
Would change mission; would increase patient population; would need to do more fundraising (hospital provides significant funding for area’s other CHC); may need to expand building; would charge no fees for uninsured/low-income; may be limited in ability to do medical billing or receive government funds.
Objective
To continue services provided for persons while expanding mission in way that serves more in the community who are in need with skills/resources currently owned by agency and broadening our mission in a manner that would draw increased community support and increase our access to persons who may be at risk for HIV/AIDS, for prevention services.
Primary Service Population
Uninsured, low-income individuals.
Services, Treatment and Care That Would be Provided
Primary care; other services could continue to be provided based on funding; no restrictions on this with free clinic status.
Organizational Structure
Policy and Oversight: Board of Directors current structure.
Administrative and Operational: Could be some limitations on medical billing; currently free clinics do not bill insurance, Medicaid or Medicare and so do not serve this population. We could continue to serve all HIV+ population and add primary care for uninsured low-income or talk with other area agencies about combining operations (nicer, larger space in medically underserved area). Potentially use volunteers to provide primary care as opposed to full clinical/paid staff.
Funding Source(s) Available and/or Needing Development
Private funding (fundraising, grants); federal funding and medical billing may be dependent on rules of free clinics (currently being negotiated among the free clinic association given health care reform changes).

Option 7: Merge with Community Health Center

Implications
Legal procedure; lose independent non-profit status; governance by CHC Board and management; could negotiate/advocate for how HIV services could be provided with merger. Could potentially maintain site and staff in some fashion. Would be subject to HRSA approval. Would change sliding fee scale.
Objective
To ensure basic primary care and HIV specialty care services for persons living with HIV/AIDS in service area given changing landscape of healthcare.
Primary Service Population
Uninsured, underinsured and low-income populations.
Services, Treatment and Care That Would be Provided
Primary care and other required services under CHC legislation.
Organizational Structure
Policy and Oversight: The CHC Board of Directors, unless some Board continuity was negotiated as part of merger.
Administrative and Operational: The CHC staff, unless staff continuity was negotiated as part of merger.
Funding Source(s) Available and/or Needing Development
Would be up to the CHC already in operation and already funded; would potentially transfer agency’s current funds to be used by CHC.

Option 8: Plan for Closure and Transfer Patients to Other Providers

Implications
Would need transition plan to ensure continuity of care for patients. Legal procedure. Would need to sell assets including building and determine use of funds.
Objective
To ensure quality of HIV care and primary care for all agency patients with a smooth transition.

Chart: Pros and Cons of Option __:

1 – ACA Change Options for a Standalone HIV Organization – Catawba Care – 2013 – http://careacttarget.org

Pros
Cons
Barriers/Challenges
Initial Feelings

1 – ACA Change Options for a Standalone HIV Organization – Catawba Care – 2013 – http://careacttarget.org