0990-RW Study Appendix D - Responses to Comments_06-14-13

Appendix d

Responses to comments from external reviewers

Table 1. Responses to Comments from External Reviewers

Topic	Comment	Change and Justification
General	Provide the interview questions to the subjects well in advance so that information can be gathered prior to the interview.	Yes: we pre-tested this and this practice worked well.
General	Consider not only if a service was funded, but also how the service impacted access to services and outcomes	No: this is a general comment, not a change request.
General	Consider starting with a written survey with a follow-up interview. Also, the current interview time of 60 minutes is too long	No: the written survey is beyond the project’s budget. The pre-test respondents did not complain about the length of the interview.
General	Add: “Is the primary care workforce adequately educated or trained to take on HIV outpatient care, including prescribing providers and other on the health care team? If no, what are suggestions to accomplish this?” Should there be other directives given to the AIDS Education and Training Centers? What needs to be done to make sure the future primary care workforce persons and other health care team members are prepared to offer appropriate outpatient HIV care?”	Yes: we edited the text of one of the questions to reflect this issue.
General	Use a sample for the survey that is representative in terms of geographic distribution, low-high incidence jurisdictions, and varying levels of experience preparing for the implementation of health reform	Yes: we will interview the universe of Part B grantees, and a representative sample of the Part A grantees and providers.
General	Include clients, case managers, clinicians, pharmacists, and community stakeholders in the sample. Also, assure anonymity by informed consent	No: these respondents are outside the project’s scope. Yes: we will use informed consent
General	Expand the topics to assess the impact of health reform on the need for expanded access o care for all PLWHA, the ability of all Parts of the Ryan White Program to wrap around insurance, and the effect that access to insurance will have on the current structure of Ryan White.	No: these questions are beyond the scope of the current project.
General	Can some of these questions be asked of HAB directly?	No: that is not part of the study design.
General	Can states decline to answer a question?	Yes: participation in the survey is voluntary.
General	Don’t have the interviewers say what is in the notes – it will save time.	Yes: the notes are not intended to be spoken by the interviewers, unless for clarification.
Introduction	Add underlined text to statement: Affordable Care Act might affect the availability and accessibility of high-quality HIV care)	Yes: we added and pre-tested that text.
Introduction	Add an educational component to the front of the survey, explaining the changes that will take place in 2014 after the ACA is fully implemented	Yes: we added and pre-tested that text.
Grantee Guide - general	Because the states are in the process of rolling out the ACA-driven directives, it may be premature to answer the question of their impact on Ryan White need. It might be useful to ask whether states are implementing ACA-driven programs that will affect RW planning.	Yes: we added a state ACA implementation question to address this comment.
Grantee Guide	Add a question from the provider guide to the grantee guide about whether the grantee is prepared for billing and provides any funding, education, technical assistance on billing of medical services and treatment.	Yes: we added this question to the grantee guide.
Grantee Guide	There are no questions about the current relationship, level of coordination, or interaction between Ryan White grantees and the state Medicaid program.	Yes: we added this question to both grantee and provider guides.
Grantee Guide	There are no questions concerning what the grantee is doing or plans to do to educate patients about the coming changes, or prepare them for the transition	Yes: we added this question to both grantee and provider guides.
Grantee Guide	Add a question, like the provider question, about what sorts of preparations the grantee may be taking (themselves) to gear up for 2014.	Yes: we added this question to both grantee and provider guides.
Provider Guide - general	Add more questions about the respondent’s experience using blended or bundled payment, as some services may be omitted in that scenario	Yes: we added this question to the provider guide.
Provider Guide	Consider asking the provider, flat out, whether they plan to continuing practicing if 50% to 90% of their patients become Medicaid patients.	No: this kind of question is being asked of providers in a different study.
Provider Guide - QA1	How would you describe your practice setting – as an academic health center, community-based clinic (non-FQHC), or a federally qualified health center	No: this information is already provided through other datasets and will be confirmed during recruitment.
Provider Guide – Q A1	Add, “How familiar are you with the ACA?”	Yes: we added this question to the provider guide.
Section B	Add a question to determine what Ryan White services utilized by PLWHA in the jurisdiction will not be covered by the ACA.	No: it is too early in the ACA implementation process to ask this question.
Grantee Guide – Q B1	Confirm that 2011 is the grant year to be reviewed.	Yes: we added this question to both grantee and provider guides.
Grantee and Provider Guide – Q B2	Clarify if these data is to include clients who receive HIV testing through the Early Intervention Service (EIS) category.	Yes: we edited the text to reflect this comment.
	Add “other insurance” as an option, specific to private policies purchased on behalf of a client (continuing an employer insurance policy, COBRA, BCBS, etc.	Yes: we edited the text to reflect this comment.
Provider Guide – Q B2	Add private insurance to this question.	Yes: we edited the text to reflect this comment.
Grantee Guide – Q B3	Should it be 133% of poverty?	No: 138% is correct.
Provider Guide – Q B3	Add dollar equivalent of the FPL – 138% around $15,000 and 138% to 400% - $15,000 to around $45,000 (8)	Yes: we added this information to the interviewer note.
Grantee Guide – Q B4	This is not likely to be available; it is not required by HRSA	No: respondents can provide this information from other sources.
Grantee Guide – Q B5	It will be difficult to estimate what percentage will be insured through the state’s future health exchange.	Yes: we replaced the original question with the text below.
Provider Guide – Q B5	Please use this question, “Under the ACA, Medicaid will be expanded to most individuals with an income under $15,000 – and premium subsidies will be available for people to enroll in plans available through the state-based exchanges for individuals between $15,000 and $45,000 – can you roughly estimate how many of your patients will enroll in either Medicaid or an exchange plan? For those who remain uninsured – why do we think this will be?”	Yes: we replaced the original question with this text.
Provider Guide – Q B6	Please use this question, “Based on the coverage that your Medicaid patients currently received – what are the gaps in services for medical and support services that you think your patients that enroll in Medicaid will have? Based on the gaps in services or barriers to care that you see for your privately insured patients – what are the gaps that you think patients enrolling in exchange plans will have?”	Yes: we replaced the original question with this text.
Grantee Guide – Q C1 and Q C3	For Part A grantees, this information is available from the table listing of the Planning Council’s ranking of priorities, which can be requested from them.	Yes: we added this information to the interviewer note.
Grantee Guide – Q C5	Respondents should be made aware that there is a waiver process in meeting this requirement.	No: this task is outside the scope of the interview.
Grantee Guide – Q C5	There is a typo. It should be “provide” not provided.	Yes: we corrected the text.
Provider Guide – Q C3	I’d define non-Ryan White program sources – do you mean Medicaid and private insurance?	Yes: we edited the text to reflect this comment.
Grantee Guide – Q D1 and Q D3	For Part A EMAs, this information is available in the table listing other funding that is submitted to HRSA as part of the grant application.	Yes: we added this information to the interviewer note.
Grantee Guide – Q D1	The question should also include the opportunity to identify funding from other Parts of the Ryan White Program in their jurisdiction	Yes: we edited the text to reflect this comment.
Provider Guide – Q D7	Reimbursement – I am not sure how to answer this. Use a new question: Consider adding a questions about whether they currently contract with Medicaid managed care plan in their state.	Yes: we replaced the original question with this text.
Provider Guide – Q E1	Add another example: “Fund the employment or use of peer counselors or volunteers to assist with patient navigation.”	Yes: we edited the text to reflect this comment.
Grantee Guide – Q E1	Some grantees also provide Medications to clients. Can they respond to this questions as well as Part B/ADAP grantees? It was also not clear that this question related only to expenditures. Will a distinction be made between cost-containment measures (that limit access for a specific period of time) vs. programmatic management (measures in place at all times for all ADAP clients)?	Yes: we will allow all grantees to respond.
Provider Guide – Q E1	Similar to ADAP – some providers have had to implement restrictive program changes due to increase demand, so I would add a question to assess to see if programs had closed to new patients or seen an increase in wait time for appointments.	Yes: we added a category for closing the program.
Provider Guide – Q E2	Consider adding: to manage or “leverage” you RW expenditures	Yes: we added the requested text.
Provider Guide – Q E3	Add: “Assuming with the ACA that you see an increase in Medicaid patients”	Yes: we edited the text to reflect this comment.
Section F - general	Ask about what type of assistance Ryan White providers might want in monitoring the transition of each patient and tracking every step of the transition process.	No: we asked a more general question than this.
Section F - general	This seems like a lot of questions related to eligibility and enrollment – which is important, but it is also important to assess level of integration with other types of service providers. I would consider combining a couple of these questions and replace with questions to assess if their program has contracted with other service providers either for their patients to receive support services, e.g., case management, mental health and substance use, or for their providers or their programs to provide HIV services, e.g. with FQHCs.	Yes: we condensed the original questions, but did not add new questions.
Section G – Q G2	Include factors such as HIV testing, expansion of insurance, reductions of drug formularies.	Yes: we edited the text to reflect this comment.
Section H	No comments