Continuing HIV Care Services in the Absence of

Ryan White FundingInterfaith Community Health Center

Bellingham, Washington

What We Decided• In February 2014, the ICHC Board of Directors voted

unanimously to relinquish the clinic’s Part C grant effective March 31, 2014.• Grant amount was approximately $400,000.• ICHC was an April 1 start date with one year left in

grant cycle before re-competition.• ICHC had been a Ryan White grantee for 11 years.• ICHC’s Ryan White Program offered a comprehensive

program of primary care, dental, case management, behavioral health, and nutrition services.• One Ryan White patient is a ICHC Board Member.

However…

Board also voted unanimously to continue the same array of services offered through

our Ryan White Program using other funding sources (e.g., 340b and Medicaid

expansion revenue)

Why We Did It• Unique nature of ICHC clinic• FQHC with approximately 14,000 patients • Only about 170 HIV patients• No stand-alone HIV program, so…• Different eligibility process for HIV patients vs. other clinic

patients (e.g., income verification every 6 months, even if insured, and residency documentation – not required of any other clinic patients)

• Different Ryan White sliding fee scale rules vs. 330 rules (e.g., no charge for patients below 100% FPL, slide beyond 200% FPL)

• Clinic EMR with CAREWare double entry• Considerable drain on Finance, Front Desk, and Medical

Records

Why We Did It (continued)• ACA implementation• Fewer uninsured patients• Likely grant underspend into the future• Strong safety net in Washington State through

state’s Early Intervention Program (although Medicaid patients are categorically ineligible)• Coverage for undocumented patients• Comprehensive dental coverage• Assistance with

co-pays/premiums/deductibles

Why We Did It (continued)• Increasing administrative burden• Eligibility verification twice annually• Very likely to have required a core services waiver • Had increase administrative staffing .2 FTE to

handle eligibility documentation• Administrative requirements were becoming an

impediment to quality care• Paper chasing by medical staff• Frustrated patients• Frequently changing requirements meant

frequent “system change,” which was disruptive to program efforts

Why We Did It (continued)

• Cost shifting – We were covering more of the costs of care with non-grant funds anyway • Guidance that more costs (e.g., medical

records, referrals, front desk) categorized as administrative costs • Patients with lapsed eligibility documentation

couldn’t be billed to grant• Compliance concerns• Retroactive policy clarifications

What Has Happened• Continue to provide same services we have

historically provided – same staff, same services• Continue to contract with our case management

partners• If anything, the relationship has become stronger• They have been understanding of our decision

• Continue to have a Consumer Advisory Group• Continue to track HAB measures, with a few

slightly modified, for QI program• No change in number of HIV patients served

What Has Happened (continued)

• Time to “drill down” into quality measures and refine systems that should have been addressed long ago• Moving towards implementation of a Hepatitis C

program• Focusing more on engagement/retention• Expanding some RW benefits to other clinic

patients (e.g., HIV nutritionist will start offering classes to patients with HIV and other chronic conditions)

What Has Happened (continued)

• Plans to work more with community partners on prevention and moving to opt-out HIV testing• Patients have rolled with the change• Those with incomes above 200% FPL are

no longer eligible for the sliding fee scale, in compliance with 330 rules

What Has Happened (continued)

• If there’s a gap, it’s dental• Medicare and privately-ensured patients have

strong dental coverage through Early Intervention Program• Medicaid adult dental program is not as

generous• Working through gaps in care for Medicaid

patients in partnership with our case management contractor