The Next Wave in AIDS Care: Reauthorization of the Ryan White CARE Act 2005-2010

Funding/Fiscal/Administrative Endeavors Should:

• Provide for a seamless system between all publicly and privately funded medical and social service systems. Ryan White should be the bridge between systems and ensure that people are not left behind or without access to care. Overlap and duplication of services would be reduced.

• Provide for adequate infrastructure, in both physical and human resources. Infrastructure includes: physical resources -- buildings, geographically appropriate locations, transportation, and clinics; as well as human resources -- trained providers, appropriate medical care providers (RN's, ARNP's, PA's, ID docs, etc.) case managers, support for family caregivers, referral network information and training to all providers.

• Provide for equitable and appropriate reimbursement rates to medical and social service providers. Reimbursement rates should be competitive to ensure an appropriate number of providers are interested in providing services. Also, the number of anticipated providers should be projected based on case rates for an area or region, geographical location should not be a barrier to rates or access to providers, available providers should be included in a referral network to allow for client choice, appropriate care (and types of care) should be universally available and not restricted geographically.
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• Build in fiscal prudence prominently featuring competition. Fiscal responsibility should be maintained at all levels of the system of care. Appropriate levels of fiscal guidelines should be maintained for federal, state and local grantors as well as all grantees. Training and support should be available at all levels to prevent fiscal abuse. Competition should be encouraged at all levels of contracting. Efforts should be made to ensure multiple applicants for services with strong emphasis on fiscal prudence and accountability.

• Build in cost efficiencies related to purchasing and procurement as well as collective purchasing. Commonalties in purchasing should be maintained by grantors, i.e.: computers, software, training, technical assistance, space allocation, and rent formulas to assist grantees. Collective purchasing should be used whenever possible; pharmaceuticals, and equipment collective pricing to allow grantees and providers the option to purchase from collective bidding rather than individual bidding.

• Address accountability at the client, provider, and administrative levels. This concept relates to fiscal prudence but also contains accountability for quality of care, quantity of services, appropriateness of care, removal of barriers, "checks and balances" at all levels, and identification of duplicate and burdensome processes throughout the system. Accountability should also have a component of training and technical assistance to help "repair" any identified issues. The cost of a new provider is much higher than working to update a current provider.

• Equitably distribute resources across geographic regions. Resources should be based on case count which will facilitate equitable distribution. Increased emphasis should be placed on accountability for grantors to ensure geographical coverage and appropriate level of providers within their geographical areas. Access to care should be portable across geographic lines to ensure provider availability and equal access to equal care in regions lacking infrastructure and providers.

• Utilize HIV data in funding formulas as soon as possible. HIV data is already being collected and can be utilized now. Identifying the areas where data is not available must be addressed to begin utilization of HIV data for planning, funding, and distribution.

• Support expanded HIV testing and counseling in clinical settings so that it may become a part of standard medical screenings. Utilize and support health departments to expand HIV testing, counseling, and training, including lab support. Increase training and utilize AETCs and other medical associations to increase testing awareness in clinical provider's settings. Additionally, making HIV testing part of routine medical care could help to further reduce stigma, support prevention efforts, and identify positives in the non-symptomatic stages, before disease progression can complicate treatment success. This would improve the patients' long-term prospects and prevent them from leaving the workforce due to health concerns.

• Understand that there are ethical considerations related to expanded HIV testing, at any level. New cases will increase the burden on existing, under-funded care systems. Mathematical certainty demonstrates that in attempting to locate more individuals through testing and outreach, the numbers of individuals requiring care and treatment will increase. Despite this fact, identification of the disease is the first step to isolating its spread. It must be remembered that this is not isolation of the individual but isolation of the spread of HIV/AIDS through knowledge and awareness. By improving reporting systems, both planning and funding levels can be better prepared for oncoming cases.