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H H S Department of Health and Human Services
Health Resources and Services Administration
HIV/AIDS Programs

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Severity of Need (SON) Index - History - Impetus for a Better Measure

The Ryan White HIV/AIDS Program delivers HIV/AIDS care to those with limited resources to pay for needed care, reaching over half a million persons in the U.S. each year. Since its beginning in 1990, the Ryan White Program has evolved to improve the way services are delivered and methods used to target funds to areas with the greatest need. Funding is limited, demanding ever-better techniques to measure need and disseminate resources accordingly.

HRSA/HAB, which administers the Ryan White HIV/AIDS Program, directs funds under several funding programs, including to cities (Part A) and States (Part B) via formula awards along with supplemental grants that direct funds to highly impacted areas according to legislative direction. In recent years, including FY2007, HRSA/HAB has taken the following factors into account in gauging severity of need: (1) HIV/AIDS epidemiology; (2) co-morbidity, poverty, and insurance information; and (3) evidence of the existence of populations with special needs. These factors reflect the1996 reauthorization of the CARE Act, which guided HRSA/HAB to define “severity of need” as:

“...the degree to which providing primary medical care to people with HIV disease in any given area is more complicated and costly than in other areas, based on a combination of the adverse health and socio-economic circumstances of the populations to be served.”

Efforts to further refine the definition of severe need are outlined in the 2006 Ryan White reauthorization, which directs the Secretary to establish a Severity of Need Index, defined as “the index of the relative needs of individuals within a State or area, as identified by a number of different factors, and is a factor or set of factors that is multiplied by the number of living HIV/AIDS cases in a State or area, providing different weights to those cases based on needs.”

There are many Secretarial requirements for the submission of the SON Index. Congressional language specifies detailed implementation steps and requires the Secretarial submission report to have the following criteria:

  • To be developed by Sept. 30, 2008
  • To be applicable across all Parts although different factors or sets of factors may differ across Parts
    The Secretary is required to submit:
    • Methodology and rationale for development of the index
    • An independent contractor analysis of the index
    • Information regarding the process for obtaining community Input on the application and development of the index
  • If the index is not completed in FY 2007 or FY 2008, the Secretary must submit an annual report outlining:
    • Progress toward having client-level data
    • Progress toward completion of the index, including information related to methodology and process for community input; and
    • Whether the index should be developed by FY 2009.

Efforts to refine severity of need measures predate the above 2006 legislative mandates. In addition to ongoing HRSA/HAB efforts, a major force for change came with the 2003 Institute of Medicine (IOM) report, Measuring What Matters. That study began in response to the 2000 reauthorization of the CARE Act, when an IOM Committee was asked to study the allocation of Ryan White Program resources and identify data and tools for assessing a community’s severity of need. The IOM panel recommended in their report that HRSA adopt a new approach to allocating Part A supplemental awards based on standardized, quantitative indicators of resource needs in different jurisdictions. Furthermore, the Committee suggested that other factors, aside from those typically reported in supplemental requests, determine resource needs. These indicators and measures would comprise a SON Index with the following characteristics:

  • A quantitative index, relying on fewer measures, transparent, reliable, and valid.
  • Data elements should be available for all jurisdictions that comprise Ryan White Program grantee service areas (therefore available at the county level) and should be periodically updated, readily available, contain sufficient variation, and be free of measurement error that would influence SON.

The IOM conceptualized SON in terms of the following function (see Measuring What Matters, p. 137):

Severity of Need =
(Disease Burden) x (Cost of Care) – (Available Resources)