Fort Smith Fights AIDS, Inc.

A Few Words about HRSA

The Ryan White CARE Act is the program that pays for all the HIV services that we provide in Arkansas.

HRSA is the funding agency in Washington, D.C. that Ryan White CARE Act dollars are funneled through. It stands for Health Resources and Services Administration. Their headquarters is located in Rockville, Maryland, just outside of D.C. I’m not so sure how much reality those folks deal with on a daily basis. I think that most have never been out of their offices and really don’t deal with HIV Disease other than in an administrative capacity for the program.

The Ryan White program is divided into several parts. Part A deals with those eligible metropolitan areas of at least 50,000 people who show a need greater than the state funding can handle (Arkansas does not have a Part A EMA). Part B funds all 50 states plus our protectorates (Arkansas receives money from this part). Parts C and D are funded directly to community health centers. Arkansas has Parts C and D through: Jefferson Comp Care in Pine Bluff, White River Rural Health in Augusta, and East Arkansas Family Health Center in West Memphis. West Memphis is also covered under the Memphis Part A geographic region.

Oversight of the program is left to the Health Department for Part B and with HRSA for the other Parts. HRSA is about as good a monitor as the Health Department is for these funds.

Being good custodians of the funds became an issue with Congress last year during the reauthorization process. This resulted in some major changes to the law as it was reauthorized (and re-named) by Congress. The main issue was that for the Parts A, B, C, and D, 75% of the budget MUST be spent on core medical services. No problem there.
We were already spending that in Arkansas. Congress then spelled out exactly what “core medical services” means. Sort of. Maybe. Perhaps. I guess………..

The interpretation becomes very foggy. It seems that ONLY those services that are paid by a medical clinic or the Department of Health can be determined to be “core medical services.” That means that because I am not attached to a clinic or draw a salary from any clinic, I cannot be a considered a “medical case manager” and any services I pay for cannot be considered a “core medical service.” Even though everything I do is considered medical case management, HRSA won’t count it as such because I fall under the category of “consortia,” something that has worked really well in the past. Over the past 17 years, we, in the state, have created a vast network of services for people with HIV through the consortia-based program. Why then are we changing everything?

Well, you have to remember that we are dealing with not only the federal government’s agency here, but also the state government’s agency. If I have learned one thing about government, it is this: “If it’s not broken, FIX IT!!!!” This seems to be what is happening in Arkansas today. Unfortunately, hiring incompetent people to try and fix was it not broken is not working out so well.

Always in years past, each district of the state would receive a portion of the Ryan White dollars to take care of the folks in those respective districts. Last year, the Health Department took back all the money for physician services. This year they took the dental money. I’m not sure what service will be usurped next, but there are several services left in our budgets: the co-pays on medications in the many, many pharmacies around the state, the insurance premiums to be paid, and the major expense, the labwork. According to HRSA, if I pay for it through my consortium, it’s NOT “core medical services.” BUT……….if the Health Department pays for it, it IS “core medical services.” I know, it makes no sense, but remember it takes a government mind to conceive of something like this. I’m not sure why they are considered medical and I’m not. As I said, I think it’s a matter of interpretation of the law.

I’m thinking that the lab issue will be decided this year as word on the street is that someone is poking around behind my back trying to find out exactly how I handle the lab issues in my district. It’s amazing that all they have to do is ask me, and they choose sneaking around. I guess it’s more fun sneaking around. Of course, this does nothing to promote trust in the state agency.

The Health Department tells us that HRSA is making all these changes. I’m sure they would say it is not their fault that this program is getting bogged down and becoming a barrier to care for folks with HIV Disease in Arkansas. Since they really don’t know what we do around the state, they are not aware that everything is slowly grinding to a halt, and it’s not something that they are even interested in hearing.

Oddly enough, I spoke with a counterpart in a large eastern state. I asked how their program worked and she told me. It was exactly as Arkansas has been operating for 17 years! Why would HRSA tell us to change to some other system of service deliveries when they are telling other states to do what we have been doing since day one????

I find it hard to believe that HRSA is requesting changes here that are causing barriers to care to pop up all over the state. One way to settle all these problems would be for HRSA to come to Arkansas, sit down with the case management staff, and answer questions about what they expect from the program. Of course you-know-who does not want that to happen. We might find out that they don’t know what they are doing!

When this program started, there were limits set on each line item. For example: the limit for any one person during the funding year for dental work was only $500.

Over the years as more money was allocated to Arkansas, those limits were raised. According to our current “handbook” the following is true:

Dental Services $2,500
Lab $1,000
Physician’s Services $320
Mental Health Services $400
Substance Abuse $400
Client Transportation $400
Vision Care $265 (This line item disappeared in 2007)

As far as the drug program component was concerned, there was a limit as to how many HIV drugs Arkansas would provide. There was also a proviso that stated that to be eligible for the drug program a person’s CD4 could not exceed 250. a viral load must exceed 35,000, or a person had to have a prior AIDS diagnosis (there were a couple more rules, but they are not important here).

It now appears that anything goes. Since dental is being paid for by the state, all a dentist has to do to exceed the above limit is send proof of necessity for the treatment plan to the Health Department and they will approve it. It doesn’t matter what is being done, it seems that they will approve just about anything!

This happened several years ago and the person calling the shots at that time wound up leaving the Department of Health in tears. I think that the circumstances surrounding that “exceptions-to- the-limits” incident had to do with parity of services across the state. At the time exceptions were being made in other districts at an alarming rate which provided care to some and no care to others, depending on where they lived in the state.

The upshot of all of this is: Get it while you can. The money will not last forever. If you need dental, give me a call. Just remember that there are not a lot of dentists in Arkansas to provide these services (in District II there are only 4).

Let’s talk about dentists. There seems to be an unlimited number of dentists across the State of Arkansas. Unfortunately for my folks with HIV, there are only ten of them that we can access with our current program. My dental database has 45 names in it. These are dentists that I have used in the past. My database covered all the counties in the western half of the state (39 counties). Now there are only three that have signed a contract with the Department of Health in my area. Three????

Amazing that only ten dentists agreed to participate statewide. I feel sure that it wasn’t a problem dealing with people with HIV, we had many, many dentists that had already been a great help to us. I think that it was the contract that they were asked to sign.

The State offered dentists a flat fee for each procedure. They wanted the dentists to accept that fee as full payment and to agree to NOT bill the patient for any overage. I can’t imagine why that didn’t work.

This has now left me with no family dentist in the Fort Smith area, no family dentist in the Hot Springs area, no family dentist in the Texarkana area, no family dentist in the El Dorado area, no oral surgeon in the Fayetteville area, and I lost my main dentist in the Little Rock area,

What’s sad is that no one seems to be really concerned about this. If I complain to the Health Department about finding a dentist for someone who lives in an out-lying area, I will be told to send them to some other dentist that HAS signed the agreement; no matter that it could be a 2 or 3 hour drive!

Once again the Health Department becomes a barrier to care.

What’s really sad is that the program office thinks that they are doing a really good job. The following quote from another disaster springs to my mind: “Heck of a job, Brownie.”

What would you do if you had a lot of money. I mean, A LOT OF MONEY. And you wanted to keep it, but you didn’t get it allocated to other agencies in a timely manner and now it has to be sent back to the government funding source.

If only you could come up with some kind of scheme to keep the money in the state, not really use it the way it was intended, but make it appear that way. Then the Feds would think that you are really terrific for trying to use the money wisely to care for people, you wouldn’t have to give it back, AND you could use for other endeavors.

The only problem is that this money has been earmarked for services (by the Feds) for folks with HIV. I guess, if you thought you were really creative, you could make it look like you were using the money to help people with HIV (even though you weren’t).

What kind of plan could this be? Well………..you could check with a database and see who has been reported with HIV Disease and not had any kind of medical services over the past years. You could then locate those people and get them back into service. What a great thing to do! What a great humanitarian effort this could be. The money could go out to the counties who would be helping to locate these people. The Feds would be so proud of us!

BUT…………..what if a group of people that actually worked WITH folks with HIV spoke up and said that the names that were provided by the database were people that, by-and-large, had either died or had moved out of state………..they would NEVER be coming back into care.

The response from the State was: All of these people will be lining up for care! We will find them and help them (and, in the process, not have to send any money back to the Feds).

I think that their vision was of this mass of people lined up and just waiting out there to come back to us so we could spend federal money on them. OR…… they just wanted to keep the money and didn’t really care to see the fallaciousness of the proposed plan about getting people back into care, and therefore refused to discuss this issue with anyone outside of their realm. (Did you know that they refer to themselves as “HIV Services”? Every time I see this or hear it I think of Queen Victoria using the royal “We.” A bit ostentatious or pretentious, I think, but I digress.)

Then, those people working the folks with HIV realized that this whole incredible plan sounds like this one division of a state agency was paying out good money for information that they already had in their possession.

Now I know that it’s just not right; me trying to throw a monkey wrench in this really well thought out plan, but no matter how this plan was explained to me, it sure sounds as though this particular state agency paid out BIG bucks to buy information that they already owned or had access to for FREE.

This sure doesn’t speak very well of the person in charge of this program. I’m wondering why they still have a job.

By the way, we in Northwestern Arkansas saw absolutely NO new people as a result of spending all of this money.

When I said “WOW” the other day in regard to the contracted physicians that are treating patients across Arkansas (six in number), I was wondering what happened to the remaining 52 that I had in the Northwest sector alone! This means that I have people seeing physicians that refused to sign a contract with The State, and consequently, their patients are having to pay their own way toward medical help. By putting a restriction on which physician a person may go to makes You-Know-Who become a barrier to care. (I mean……6 physicians in the ENTIRE state??? Come on now!)

Let’s look at the dental situation: Eight dentists who signed contracts with the state. Eight for the entire state! I used to have around 40 just for the Northwestern area. I turned in all the names, but apparently they didn’t want to participate in this program, or (most likely) they didn’t want to have to deal with The State. The only solution to helping people with dental expenses now is to ship them around the state like baggage to any contracted dentist that can perform the needed procedures on them. Perhaps a contract with UPS for the shipping might help save us some money in transportation costs. This looks like yet another barrier to care to me.

I was going to blog my journal that began back in 1991 when the state of Arkansas’ HIV Services Program began.  However, that was a lot of words ago and I have decided to focus on the changes that are happening around us at the moment.

According to the administrator of this program, the Feds have made some changes in the way services are paid  for.  The Feds are looking at what they call “medical case management.”  No one can say for sure just exactly what makes a case manager “medical,”  but apparently I’m not one!  The state (meaning the Arkansas Department of Health) is taking over the billing and payment of several services to date. They will be doing the same for the remaining services in the future.

Right now they are direct paying to contracted services such as physicians and dentists.  In the state of Arkansas there are now 6 contracted physicians and 8 contracted dentists.  Wow!  I hope that everyone lives near one of those contracted folks, otherwise they have quite a hike to access care.

Wait until you hear about the bizarre plan to expend money so it would not have to be turned back to the Feds.