Under the historic rule, providers would be paid to treat the homeless

Federal regulators made history earlier this year when they introduced a new rule that allows hospitals, doctors and other providers to be reimbursed for providing health care to homeless Americans.

In April, the federal Centers for Medicare and Medicaid Services proposed for the first time that homelessness be recognized as a social determinant of health. Included in its annual review of the Hospital Prospective Payment System (IPPS), the proposal is designed to improve patient safety and promote health equity. When that proposed rule became final on August 1, it required payment to begin on October 1, as CMS explained here.

I would say this development is historic, said Karen Hacker, MD, MPH, director of the CDC’s National Center for Chronic Disease Prevention and Health Promotion. I say that because the insurance companies usually didn’t pay for these services, but all of us in public health and clinical medicine understand that you can only do so much in the clinical system if the person you’re working with doesn’t have a safe place to stay.

Because the rule went into effect this month, the health system may not make payments until January, she added. What we’re seeing now is that the health care system is beginning to determine how to provide the homeless with the specific services they need, Hacker said. The other day we heard about a health system using Instacart and Uber to deliver food to the homeless, which shows how health systems are adapting to this rule.

A game-changing rule

On October 16, CNN published this article, Health care game changer? Feds step up care for homeless Americans, from KFF Health News. Journalist Angela Hart, senior correspondent for KFF Health News, wrote a game-changing article and then added another for KFF Health News, Pregnant and Addicted: Homeless women see hope in street medicine. In those articles, Hart explained that California is leading efforts to provide comprehensive medical and behavioral health care to the homeless because Gov. Gavin Newsom’s administration standardized payment for street medicine through California’s Medicaid program, called Medi-Cal.

For healthcare journalists, federal and state payments for homeless care are important because communities and nonprofit hospitals can now reach this population, which seems appropriate given that nonprofit hospitals receive tax breaks for their nonprofit and community status. Journalists should ask what steps these hospitals are taking to find and treat homeless people.

(Over the past year, we’ve covered how nonprofit hospitals have failed to provide the care the needy need. See Why Hospital Charity Care Needs More Intensive Coverage , and this tip sheet, Nonprofit Hospitals Game the System at the Cost of Patients.)

Reporters should also 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 question of costs and benefits

I think of this issue as a total cost of care issue, commented Sachin H. Jain, MD, CEO of SCAN Health Plan, a Medicare Advantage health plan in Long Beach, California. There is a 10 or 100 billion dollar question 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 cares for just over 1,900 homeless people in six California counties, Jain said in a recent interview .

Just one extremely ill homeless woman could cost the health care system $1 million or more, which most insurers won’t cover, Jain noted. Still, when a homeless person goes to the hospital, their insurance company pays for emergency room visits, hospital stays and, if necessary, intensive care, 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 homeless care providers was the Institute for Street Medicine, an international nonprofit in Ingomar, Pa., that facilitates care for the unsheltered homeless.

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 co-founding 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 who treat the homeless on the streets did not try to get paid because CMS did not issue a point-of-service (POS) code for such care, which Medicare and Medicaid require to approve payment. But other providers have billed insurance companies using a code that allows payment for treating homeless people from a van or other mobile unit.

From that survey, we learned that many of our respondents did not charge, but that what they did was fully compensable, he said.

In 2021, the institute petitioned CMS to pay for homeless care, Feldman explained. In June, the institute announced that CMS is preparing to issue POS 27, a service code that allows providers to provide care in a non-permanent location on the street or in an emergency setting.

Resources

• CMS Proposes Policies to Improve Patient Safety and Promote Health Equity, April 10, 2023 press release announcing a proposed rule to reward hospitals that provide high-quality care to underserved populations.
• Home Page of the FY 2024 IPPS Final Rule CMS Hospital Prospective Patient Payment System Final Rule
• Reports on the 2024 Final Rules, CMS IPPS, and the Future Long-Term Care Hospital Payment System
• Summary version of the handbook on how to use Medicaid to help homeless people 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; Dangers of Block Grants or Capita Caps and Guiding Principles for Reform, undated from National Council on Homeless Health Care.
• New homelessness crisis in years. Byrne, T., Culhane, D., Doran, K., Johns, E., Kuhn, R., Metrauk, S., & Schretzman, M. (2019). New homelessness crisis in years.
• Also check out this article on health care for the homeless: Author Tracy Kidder and Dr. Jim O’Connell open HJ23 in St. Louis with an inspiring keynote.
• Rough Sleepers: Dr. Jim O’Connell’s Urgent Mission to Bring Healing to the Homeless, Penguin Random House, 2023.
• Boston Health Care Program for the Homeless