MN HIV Services Planning Council
Meeting Minutes for April 12, 2005
Redeemer Missionary Baptist Church

 

 

I.          Welcome and introductions; lighting of the candle

Introductions were made and Dan Capouch lit the candle.  Dan spoke of Ryan White and his leadership in bringing HIV into the consciousness of Americans and spoke of an HIV+ 9 year old South African, named Nikosi Johnson, who asked others to “Do all you can with what you have with the time you have in the place you are.”

 

II.          Review the minutes and proposed agenda

Gary Novotny pointed out he was present at the last meeting.  The name at the top of page 5 should be “Schering-Plough”.  Minutes were accepted with the changes by unanimous consent.  The agenda was accepted as written.

 

III.   Open Forum

Aaron Keith opened the floor for other discussion.  He said that some members had voiced the need to address allocations.  No members were prepared to address allocations issues at this time.

 

          Aaron Keith Stewart, prevention for positives update

The main priority is the partnerships on prevention for positives between the CDC, HRSA, and NIOH.  Aaron Keith has several articles available for Planning Council if members would like to look at them.  CDC and HRSA have provided funding to evaluate several HIV prevention for positives demonstration projects.  Some of these initiatives include ideas such as including HIV screening in routine physicals, etc.  Sixteen demonstration projects across the country use self-interview to assess HIV transmission risk.  CDC has “Debbie” projects throughout the country.  The one in MN is prevention for positives geared towards the African American MSM community.  The U of MN project is to adapt and tailor a program called Community Promise to the African American population.

 

IV.             Co-chair update

Paul presented the co-chairs update.  Planning Council members met with DHS Assistant Commissioner Colman for an ADAP update.  In the short term it now appears that there will not be a shortfall because of the shift to Medicare Part D.  One remaining issue is that the Medicare Part D program requires certain actions be taken that are time sensitive and will require training for providers to ensure clients needs are met.

 

The MAP bill is proceeding through the Senate.  Paul had no information about any House action on the bill.  Today is AIDS Action Day at the capital; several Planning Council members are planning to attend.

 

Evaluations will be handed out at the end of the meeting; please fill them out and return them to Mary Doyle.

 

The Council holds an evening meeting once a year and asked members to look at their calendars and reserve the September Planning Council meeting for the evening meeting

 

 

V.          Making ethical decisions regarding diminished resources

Technical Assistance from Angela Amondi Wasunna

Jonathan introduced Angela, who is a Hastings Center for Bioethics consultant.  The Hastings Center is a nationally recognized ethics think tank.  Angela’s task is to assist the Planning Council to develop an ethical framework for rationing health care resources.

 

Angela began her presentation with the statement that most people believe that healthcare should be based on need and not ability to pay.  Despite this belief every society has to determine limits to health services.  One major macro-ethical question is why is there a scarcity in the first place?  There are several issues to consider including funding decisions and actual availability of the resource.

 

Angela introduced several principles and concepts of ethical decision-making.  These principles may conflict or reinforce each other.  They include:

o       Dignity

o       Autonomy

o       Equity - treat like case alike

o       Distributive Justice – resources should be distributed in a fair, but not necessarily equal manner

o       Utility

o       Efficiency – for society’s good, not individual; reach the most people in the best way

o       “Maximin” Principle

o       Non-Maleficence - do no harm

o       Beneficence - duty to help others

o       Truth-telling - honesty and integrity

o       Professional responsibility

o       Priority-setting – more a concept than a principle

 

She then presented six rationing truths:

o       Rationing decisions cannot be avoided when there is scarcity.

o       Medical rationing is a highly political process.  An example is the decision in 2001 to make government officials were higher priority than postal workers to receive Ciproflaxin for possible anthrax exposure even though postal workers were more likely to be exposed.

o       Criteria for medical rationing are never purely medical.

o       Rationing decisions require input from multiple players.

o       The process to create criteria is as important as the criteria itself and must be seen as legitimate to affected parties.

o       There will always be implicit rationing; explicit rationing has known criteria.  Implicit rationing is generally discretionary and is usually done by healthcare professionals based on professional judgment.

 

Mary Doyle said that in terms of the Council setting priorities and allocations these are the types of things we will face routinely as we continue doing our work.  Andrea said that disparities among marginalized persons are significant.  Mary Doyle added that among ethnic groups health outcomes are much poorer and Minnesota has the biggest difference in some health care outcomes.

 

There are several ethical models to consider; the following models are based on social justice theory.  The Utilitarian Model states that everyone should be provided access to the same benefits, goods, and services on the same basis.  The Libertarian Model places emphasis on contribution and merit in a free market arrangement.  The Maximin Principle requires allocation priority of scarce resources should be given to the worst off or to the least advantaged.  While there is not much consensus on which model or combination is best, some theories are better suited than others.  According to the World Health Organization, rationing policies should be clear, simple, efficient, equitable, nondiscriminatory, legitimate, measurable, sustainable, and legal.

 

Creating Processes for Decision-Making

The lack of consensus means that there should be acceptable fair process for setting limits.  The process requires input from multiple players and should be:

o       Public and Transparent - have input from stakeholders; open communication; be evidence based; seek to resolve conflicts by creating grounds for reconciliation; stakeholders should be involved participants and not token members of the process; ensure differing points of view are considered and addressed

o       Have Relevance - policies are simple and geared towards the consumer; information is relevant to consumers; the process guards against using non-relevant factors for decision making

o       Have a Revisions and Appeals Mechanism

 

Dan made note of the fact that we are constantly trying to make decisions on utilitarian and other principles against an overwhelmingly free market model of healthcare.  Troy pointed out that the US doesn’t have a coherent basis for decision-making as a whole.  Angela agreed that one of the major challenges is that all models are in motion at one time, which makes weighing them and making decisions more difficult.  She pointed out that even in Europe, where healthcare access is generally more universal and rationing systems are well defined, these decisions are still a difficult issue.

 

Angela then discussed funding.  Jonathan pointed out that during reauthorization of the CARE Act one thing that is often brought up is that the planning process is costly.  Angela discussed several pitfalls in this process.  The first is that we have to be careful not to get too caught up in procedural justice and loose sight of the fact that the goal is social justice.  Another problem with this approach is that those who are excluded in the program should at least understand the reasoning for their exclusion and can rationally abide by it.  Another pitfall is that sometimes when the criteria are made public, some will people are willing to endanger their own health in order to qualify.  An example from South Africa is women with HIV who become pregnant in order to get on the rationing list, because they are not removed once they are on the list.

 

Dave asked for information or discussion of the reality that when rationing begins someone would be a “loser” and how to deal with that situation and other rationing decisions.  Andy asked for more information about factoring in the needs of individuals and the ethics of end of life care.  Angela said she tried not to use business models and stay with values based models.

 

Megan asked for feedback and suggestions about last year’s allocations process.  Jonathan said there has been some discussion already.  Mary Doyle will get the materials for Angela to review.  Dave said another issue for the next meeting is to give direction on how to use the Continuum of Prevention and Care to structure the decision-making process.  Troy said that it would be useful for us to understand what is already rationed and why.  Jonathan said that another point to consider is that success in the Ryan White CARE Act’s goal of helping people access care could result in a greater demand for services.  Dave added that caps on program capacity are a reality and should be taken into consideration.  Aaron Keith asked if there is a checklist or worksheet available for use during these processes; Angela will look into tools to assist application of ethical principles to the decision making process.

 

Jonathan said Angela would be back on April 25.   Jonathan recommended designating this as a special Planning Council meeting.  Mary Doyle asked Planning Council members to contact her if they wish to come so she can plan the venue.

 

BREAK

 

V.                 Title I update Jonathan Hanft

Jonathan presented the 3^rd quarter spending report and pointed out that at this point we would look for 75% of funds spent.  The actual figure of 67% reflects the impact of carryover funds. He directed members to the comments section for additional reasons for funds being over or under spent at this point in time.  Hennepin County contracts are about 82% complete through the county execution cycle.  The goal is to have all in place before the next invoices are due so payment can be made.

 

An upcoming HRSA Conditions of Award requirement is Planning Council Reflectiveness, which is due based on recent new members.  We are in compliance on that and it is ready to be sent in.

 

VII.   Title II and ADAP update, Dave Rompa

Dave reported that the five full time paid Fuseon slots would remain, but will eventually those people will move to insurance.  Schering-Plough has sixteen slots for Hepatitis C care free of charge.  The Schering-Plough program requires the motivation to work to maintain the regimen because if someone leaves the program the slot is lost.  The clinic has identified 22 people; MDH estimates there are 500 PLWH/A who are Hep C+.

 

DHS did not get the alcoholism grant; there has been no feedback to date.

 

Amy’s position must be posted internally first, then it can be opened to the public.  Amy sends good wishes from Morning Star, Iowa and starts her position as Head Librarian this week.  Dave also reported that Roger from RAAN is moving to South Dakota.  Ali (intern) is leaving and Dave wanted to make sure he credits her with creating the housing report.

 

The DHS website address is: www.dhs.state.mn.us/HIVAIDS

 

The mental health program is up and running and has conducted three training sessions to date.

 

Kaiser ADAP report is being released tomorrow by the Kaiser Foundation and should be available after 1pm CST.

 

MDH will release new epidemiology data on Friday, April 15.  Kip and Dave will be going to Washington, DC for the NASTAD conference.  While they are there they plan to visits on Capitol Hill.  Aaron Keith, Redwan, and Dave will attend the annual ADAP conference next month.

 

Planning for Medicare Part D is continuing and trainings will start in June for providers with consumer training to follow.  DHS thinks that 70-75% of clients will be able to transition easily to Med D.  A question asked of the commissioner is can rebate dollars be used for those remaining who fall into gap between Med D and state subsidies.  The state ADAP forecast is better because of Med D coverage.  DHS also found out that they can receive a rebate on every drug used by ADAP, not just those on formulary.  Legislature still has not decided what to do with Minnesota Care and GAMC programs; we do not know what will happen with reauthorization of the RWCA.  Dave cautions that even though we may be fiscally strong through June 2007, we don’t have assurance on how the above will play out and have to be proactive to meet needs.

 

Mary Doyle asked Dave to address the ADAP un-enrollment issue.  Dave said that because of the small numbers leaving the ADAP program annually, if enrollment is just stopped and a wait list started there still may not be enough funding to cover those prioritized by the wait list criteria.  That would mean that some of those already enrolled would need to be un-enrolled to accommodate the wait list criteria. Jonathan asked if Dave knew what the average income of those on ADAP is.  Dave has it and will get it to him.  Redwan said that most clients are 135% of FPG; Dave said 135% and under will be eligible for state subsidies.

 

Dave said Dan Schreiner, our ADAP consultant, is now full time employee in the Medicare Part D Ombudsman Office, which gives us an HIV sensitive contact in that office.

 

VIII.          Committee written reports;time for questions, discussion

Planning and Priorities Committee

·        ACTION ITEM

Allocations recommendations for final award.  Dan presented the final allocation recommendation for 2005 (green sheet).   It wasmoved and seconded to accept the motion as written.  The motion passed with one abstention.

 

HIV Positive Committee

Retreat update – Andy shared that the HIV+ committee met for two days with consultant Lennie Green (HRSA) to work on a committee vision and mission Andy will wait to report further developments until after the next HIV+ committee meeting.

 

Needs Assessment and Evaluation Committee

Gary shared that the committee is continuing to review SARs in order to make them more comparable to each other.  There is also ongoing work on a Geographic analysis that Becky Kroll has done using the 2003 Needs Assessment information.

 

Community Participation Committee

   Newsletter distribution – the latest newsletter has been distributed and the committee is planning new articles. 

 

Operations Committee

Willie said the committee did not meet last time and that new members are being oriented.

 

ADAP Ad Hoc Committee

Francis reported that Angela’s ethical decision-making presentation was very informative; the committee will discuss plans for its use in their next meeting.

 

IX.          Announcements, evaluation, next agenda

Andrea will be presenting a workshop at the Minneapolis Urban League next Wednesday, April 20.  The topic is “African Americantransgender issues and HIV/AIDS” and is geared towards health care providers.  To enroll call 612-302-3200.

 

Documents distributed at or before the meeting:

·        Agenda and minutes from March 8^th meeting

·        Written committee reports

·        Year 10 (FY2005) Allocations Proposal

·        Action item summary

 

MOTION: Gary moved Andy seconded to adjourn.

Adjourned at 11:25 a.m.