Federal regulators made history earlier this year when they introduced a new rule that allows hospitals, physicians and other providers to be reimbursed for delivering health care to homeless Americans.
In April, the federal Centers for Medicare and Medicaid Services proposed for the first time to recognize homelessness as a social determinant of health. Included in its annual revision to the Inpatient Prospective Payment System (IPPS), the proposal was designed to improve patient safety and promote health equity. When that proposed rule became final on Aug. 1, it called for payment to begin Oct. 1, as CMS explained here.
“I would say this development is historic,” said Karen Hacker, M.D., M.P.H., director of the CDC’s National Center for Chronic Disease Prevention and Health Promotion. “I say that because typically insurance companies have not paid for these services, yet all of us in public health and clinical medicine recognize that you can only do so much in the clinical system if the individual you’re working with does not have a safe place to stay.”
Since the rule became effective on Oct. 1, the health care system may not make payments until January, she added. “What we’re seeing now is the health care system beginning to determine how to get homeless people the specific services they need,” Hacker said. “The other day we heard how one health care system was using Instacart and Uber to deliver food to the homeless, which shows how health care systems are adjusting to this rule.”
A game-changing rule
On Oct. 16, CNN published this article, “Health care ‘game-changer’? Feds boost care for homeless Americans,” from KFF Health News. The journalist Angela Hart, a senior correspondent at KFF Health News, wrote the game-changer article and then added a second one for KFF Health News, “Pregnant and Addicted: Homeless Women See Hope in Street Medicine.” In those articles, Hart explained that California is leading the effort to deliver full-service medical and behavioral health care to homeless people because Gov. Gavin Newsom’s administration standardized payment for street medicine through California’s Medicaid program, called Medi-Cal.
For health care journalists, federal and state payments to care for the homeless is important because community and nonprofit hospitals now can reach out to this population, as seems fitting given that nonprofit hospitals get tax breaks for their nonprofit and community status. Reporters should ask what steps these hospitals are taking to find and treat the homeless.
(Over the past year, we covered how nonprofit hospitals have failed to provide care for the needy as required. See, “Why hospital charity care requires more intensive coverage,” and this tip sheet, “Nonprofit hospitals are gaming the system at patients’ expense.”)
Journalists also should ask hospital administrators, clinicians and federal regulators what steps they are taking to find and treat people who are homeless, how much Medicare and Medicaid are paying to treat them and whether such spending will result in any savings, as the new rule suggests.
A cost vs. benefit question
“I think about this issue as a question of the total cost of care,” commented Sachin H. Jain, M.D., CEO of SCAN Health Plan, a Medicare Advantage health plan in Long Beach, Calif. “There is a $10 billion or $100 billion question related to this population.”
Recognizing that homelessness is not only a health care issue but also an economic issue, SCAN Health Plan began paying teams of providers to care for the homeless in 2021. This year SCAN is caring just over 1,900 homeless people in six California counties, Jain said in a recent interview.
Just one extremely ill homeless person could cost the health system $1 million or more, which most insurers will not cover, Jain noted. “Yet, when a homeless person goes into a hospital, their insurance company pays for the emergency room visits, the inpatient stays, and for intensive care, if necessary,” he said. “But we won’t pay for housing because health plans don’t necessarily have the flexibility to do the obvious things for people.”
Health care on the street
One of the groups that supported the effort to pay providers to care for the homeless was the Street Medicine Institute, an international nonprofit organization in Ingomar, Pa., that facilitates the care of unsheltered homeless people.
The institute’s mission is to train and equip health care providers and others to do this work, said Brett J. Feldman, a certified physician assistant and director of USC Street Medicine. In addition to being a co-founder of the program at the Keck School of Medicine at the University of Southern California, Feldman is an associate professor of medicine at the institution.
In a 2018 survey of street medicine providers across the U.S., the institute learned that many of those treating homeless people on the streets were not attempting to get paid because CMS had not issued a place of service (POS) code for such care, which Medicare and Medicaid require to approve payment. But other providers were billing insurance companies using a code that allows payment for treating the homeless from a van or other mobile unit.
“From that survey we learned that many of our survey respondents weren’t billing, but that what they were doing was completely reimbursable,” he said.
In 2021, the institute petitioned CMS to pay for the care of the homeless, Feldman explained. In June, the institute announced that CMS was preparing to issue POS 27, a service code to allow providers to deliver care, “in a non-permanent location on the street or found environment.”
Resources
- CMS Proposes Policies to Improve Patient Safety and Promote Health Equity, press release April 10, 2023, announcing proposed rule to reward hospitals that deliver high-quality care to underserved populations.
- FY 2024 IPPS Final Rule Home Page, CMS Hospital Inpatient Prospective Payment System final rule
- FY 2024 final rule fact sheets, CMS IPPS and Long-Term Care Hospital Prospective Payment System
- Condensed Version of a Primer on How to Use Medicaid to Assist Persons Who Are Homeless to Access Medical, Behavioral Health, and Support Services, undated document from the federal Department of Health and Human Services.
- Medicaid and Health Care for the Homeless; the Dangers of Block Grants or Per Capita Caps and Guiding Principles for Reform, undated from the National Health Care for the Homeless Council.
- The Emerging Crisis of Aged Homelessness. Byrne, T., Culhane, D., Doran, K., Johns, E., Kuhn, R., Metraux, S., & Schretzman, M. (2019). The Emerging Crisis of Aged Homelessness.
- See also this article about health care for the homeless: Author Tracy Kidder and Dr. Jim O’Connell open HJ23 in St. Louis with inspiring keynote.
- Rough Sleepers: Dr. Jim O’Connell’s urgent mission to bring healing to homeless people, Penguin Random House, 2023.
- Boston Health Care for the Homeless Program
