February 13, 2020
Sachin H. Jain, MD, MBA1,2; John Baackes3,4; James J. O’Connell, MD5,6
Author Affiliations Article Information
·
1CareMore and Aspire
Health, Cerritos, California
·
2Stanford University
School of Medicine, Stanford, California
·
3LA Care, Los Angeles,
California
·
4SNP Alliance, Washington,
DC
·
5Boston Healthcare for the
Homeless, Boston, Massachusetts
·
6Massachusetts General
Hospital, Harvard Medical School, Boston
JAMA. Published online February
13, 2020. doi:10.1001/jama.2019.22376
The US
Census Bureau estimated that in 2018, more than 550 000 individuals experienced
homelessness on any given day.1 Homelessness is both a recognized
cause and a result of health problems. There has been a movement over the past
several years to include housing as a health care intervention by several key
cities and municipalities, notably, San Francisco, New York, and Los Angeles.
Although these programs have had some success with small populations of
patients, their reliance on city budgets raises questions about scalability.
The creation of a homelessness-focused special needs plan, a type of Medicare
Advantage insurance plan aimed at meeting the unique care needs of specific
high-need populations, may be an approach through which to sustainably finance
health care delivery for homeless individuals.
Special
Needs Plans
Special
needs plans, first authorized by the Centers for Medicare & Medicaid
Services (CMS) in the Medicare Modernization Act of 2003, are not widely known,
but are a form of Medicare Advantage plans that have quietly increased in
popularity and now include almost 3.2 million patients who are enrolled in
Medicare in 734 different plans.2 Individuals are eligible if they
are eligible for Medicare and meet criteria for inclusion in a plan type. CMS,
sometimes in coordination with state Medicaid agencies, administers these plans
in partnership with managed care organizations.
Special
needs plans enable specialized benefit designs for particular chronic
conditions (eg, end-stage kidney disease, diabetes, heart disease, chronic
obstructive pulmonary disease) or for groups of people with specialized health
care needs (patients eligible for both Medicare and Medicaid or patients
requiring an institutional level of care). Although special needs plans vary
widely in their design, organization, and care delivery models, they are
characterized by highly focused clinical model requirements, higher degrees of
care coordination, and care that is closely tailored to meet the specific needs
of the populations served. These plans are regulated by CMS to ensure patients
receive care consistent with predesigned standards. For example, diabetes
special needs plans offer specialized benefits, physician choices, and drug
formularies to optimize care for individuals with diabetes; institutional
special needs plans focus on the specific care needs of patients who are
homebound; and dual-eligible special needs plans coordinate benefits for
patients who are eligible for both Medicare and Medicaid. Select special needs
plan types have been associated with less emergency department use, less
hospital use, and fewer readmissions.3
The
Homeless Special Needs Plan
The
homeless population—composed of many individuals who qualify for Medicare
because of age or disability or Medicaid because of low income—is growing again
after years of decline and is projected to increase over the next decade.4 Special needs plans offer a
possible solution to help provide care for the homeless population that is not
effectively addressed by traditional health care delivery models.
Homeless
individuals enrolled in traditional fee-for-service Medicare and Medicaid are
often underserved by a delivery system that is not designed to address their
wide range of complex social and behavioral needs.5 Fee-for-service payments result
in a focus on addressing the effects of homelessness, not the related
underlying mental health, substance use, or economic or social conditions; this
care is expensive and suboptimal. Homeless individuals are often cared for by
clinicians on the streets or in shelters and require intensive case management
and care coordination, including close engagement with local housing
authorities, medical care professionals and centers, inpatient facilities, and
other programs.6 Fee-for-service Medicare and
Medicaid financing is not designed to address homelessness and deliver this
type of coordination, despite the best efforts of many well-intentioned
homelessness health care delivery organizations. For this reason, the creation
of a new approach in the form of a homeless special needs plan that would fully
capitate monthly payments to organizations willing to assume full financial
risk for the care of homeless individuals may be effective in driving better
outcomes and higher degrees of care coordination.
As with
other types of special needs plans and Medicare Advantage plans, Medicare
Advantage organizations offering homeless special needs plans would need to
receive adequately risk-adjusted payments per member per month that reflect the
total true cost of caring for patients. Those payments could be used to fund
all Medicare Part A, B, and D benefits, including professional services,
institutional care expense, and pharmacy benefits. Depending on the design
selected, plans could be administered through the Medicare program, Medicaid
through Medicaid managed care partners, or through a coordinated model leveraging
the infrastructure of both programs.
The
specific model of care requirements designed for any medical group that aims to
provide medical services for homeless populations might include mobile,
community, and street-based medical care delivery; intensive psychiatric and
addiction treatment services for patients who need it; management of underlying
diseases that may contribute to or be influenced by an individual’s state of
homelessness; case management in collaboration with local housing agencies; transportation
to and from health care and housing; work to secure safe and stable housing;
and, in some cases, respite care. It is likely that delivery organizations that
provide homeless special needs plans would include traditional clinicians and
centers that provide care for homeless individuals, such as federally qualified
health centers; local, state, and federal agencies; and community organizations
with experience addressing the needs of homeless individuals.
Suggestions
for a Homeless Special Needs Plan Pilot Design
This
idea for a homeless special needs plan should first be pilot tested by the
Center for Medicare and Medicaid Innovation (CMMI). If the results of the pilot
program suggest that the program leads to lower costs for people experiencing homelessness
or housing instability; better clinical outcomes; and, ultimately, a lower rate
of homelessness, especially for patients whose homelessness is associated with
treatable mental illness, addiction, and other debilitating medical conditions,
then it could be expanded to the entire Medicare Advantage program.
To
test, implement, and scale homeless special needs plans, CMS would need to
address several key operational challenges. First, actuaries would need to
establish payment adjustments that would adequately account for costs of
appropriately providing the range of health care and other services needed by
enrollees in a homeless special needs plan. Because current diagnosis-based
risk adjusters are unlikely to accurately estimate all of the medical
expenditures of homeless individuals, a payment factor should be developed,
similar to the frailty adjuster already used, to account for the higher
expenditures associated with social determinants and drivers of health.
Second,
CMMI would have to derive a definition of homelessness that
could easily and effectively be applied. For simplicity, homelessness could be
defined as more than 6 months of unstable housing. Verification will be
challenging, but there are potential forms of documentation (eg, shelter
records, eviction notices) that could be used to establish chronicity. CMMI
should also consider defining criteria to identify at-risk beneficiaries to
enable health plans to help patients avoid the negative effects of homelessness
and partnering with other agencies, such as the US Department of Housing and
Urban Development, to help provide financial support, such as subsidies,
vouchers, and access to rapid rehousing programs.7 Similarly, it would be necessary
to determine if and when a formerly homeless individual who has been supported
under a homeless special needs plan is no longer eligible for the plan. To
avoid recidivism but maintain cost savings, lifetime eligibility could be
considered, but with a stepwise decline in additional risk modifiers to adjust
for the expected lower average medical costs once an individual has stable
housing.
Third,
CMS would have to develop model-of-care requirements that could be consistently
applied across the variety of rural and urban geographies in which individuals
experiencing homelessness live, but also enable the flexibility to meet local
and context-specific needs. Enabling multiple potential design concepts for
homeless special needs plans in pilot programs through a CMMI demonstration
could help identify the correct long-term guardrails around program
definitions.
Fourth,
there will need to be flexibility for real experimentation on benefit design
regulatory flexibility around issues, such as the medical-loss ratio, to
optimally serve this diverse population. Benefits have historically been
defined by Medicare Advantage plans independent of the individual’s housing
status. Recent flexibility in benefit design to address social determinants of
health will be helpful as plans develop appropriate network and benefit
designs, but additional flexibility may be needed to establish appropriate
solutions.8
Opportunities
and Challenges
The homeless
special needs plan pilot program should measure total cost of care; quality of
health care delivered; and, importantly, reductions in rates of homelessness.
To be scalable and meet the requirements of scaling a CMS demonstration, the
pilot program would need to deliver on total cost of care savings. Given the
transient nature of the homeless population and challenges locating and
tracking individuals, the effectiveness of this program may be difficult to
measure. There are also reasonable questions about how much social spending
should be absorbed by health care budgets. Although the higher levels of
interagency coordination enabled by homeless special needs plans, along with
more effective management of homelessness-precipitating health conditions, may
lead to lower overall public spending, this is an untested question that would
have to be answered empirically by a CMMI demonstration.
The
current administration has defined addressing homelessness as a key
administration priority.9 Homeless special needs plans that
are built within the existing regulatory framework guiding special needs plans,
or, alternatively, Medicaid,10 offer a potential solution to
the health care contributors to homelessness. CMMI should test homeless special
needs plan models to determine the extent to which alternative models of health
care delivery and financing could help alleviate the growing national challenge
of older adults experiencing homelessness and its associated health conditions.
This collaborative, multisector approach could hold significant promise to
reducing the number of homeless individuals and increasing access to health care
and related services through levels of coordination that are otherwise
impossible to achieve.
Article
Information
Corresponding
Author: Sachin H. Jain, MD, MBA, CareMore and Aspire Health, 12900
Park Plaza Dr, Ste 150, Cerritos, CA 90703 (shjain@post.harvard.edu).
Published
Online: February 13, 2020. doi:10.1001/jama.2019.22376
Conflict
of Interest Disclosures: Dr Jain reported being employed by
Anthem, Inc, a national managed care company. No other disclosures were
reported.
References
1.Homeless
statistics by state. US Interagency Council on Homelessness website. https://www.usich.gov/tools-for-action/map/#fn[]=1400&fn[]=2900&fn[]=6000&fn[]=9900&fn[]=13500.
Accessed December 23, 2019.
2.About
SNPs. SNP Alliance website. http://snpalliance.org/about-snps-mmps/.
Accessed December 23, 2019.
3.McGarry
BE, Grabowski DC. Managed care for long-stay nursing home
residents: an evaluation of Institutional Special Needs Plans. Am
J Manag Care. 2019;25(9):438-443.PubMedGoogle Scholar
4.Baggett
TP, Berkowitz SA, Fung V, Gaeta JM. Prevalence of
housing problems among community health center patients. JAMA.
2018;319(7):717-719.
ArticlePubMedGoogle ScholarCrossref
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5.Hirschtritt
ME, Binder RL. Interrupting the mental
illness-incarceration-recidivism cycle. JAMA.
2017;317(7):695-696. doi:10.1001/jama.2016.20992
ArticlePubMedGoogle ScholarCrossref
ArticlePubMedGoogle ScholarCrossref
6.Koh
HK, O’Connell JJ. Improving health care for homeless
people. JAMA. 2016;316(24):2586-2587.
ArticlePubMedGoogle ScholarCrossref
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7.Dettling
M, Anghelescu I. Housing for homeless adults with mental
illness. JAMA. 2015;313(24):2493.
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8.Thomas
KS, Durfey SNM, Gadbois EA, et al. Perspectives
of Medicare Advantage Plan representatives on addressing social determinants of
health in response to the CHRONIC Care Act. JAMA Netw Open.
2019;2(7):e196923.PubMedGoogle Scholar
9.Givas
N. Exclusive: Trump shares plans to combat homelessness and mental
illness in interview with Tucker Carlson. Fox News website. https://www.foxnews.com/politics/trump-tucker-exclusive-interview-homelessness.Published
July 1, 2019. Accessed December 23, 2019.
10.Bamberger
J. Reducing homelessness by embracing housing as a Medicaid
benefit. JAMA Intern Med. 2016;176(8):1051-1052.
February 24, 2020 Response to Viewpoint:
Homeless Special Needs Plans for People Experiencing Homelessness, Feb. 13
Valerie Swenson, MA and BA, CPC; MN Rep. Mindy Greiling | Health
Care for All Minnesota
In response to Sachin H. Jain's Feb. 13th Viewpoint, it is
important to note that Jain is employed by a Medicare Advantage HMO. Medicare
Advantage plans are highly profitable insurance plans. They are privatized
versions of our traditional Medicare program. They gain a marketing “advantage”
by including the word “Medicare” in their name. They profit off of what was
originally meant to efficiently serve all of us - our publicly funded Medicare
program. The U.S. General Accountability Office report 16-76 found that
traditional Medicare had to send $14 billion in unwarranted payments in a
single year to the Advantage plans because of their ability to
game the system.
Jain apparently is proposing that Congress address the homelessness problem by funneling even more tax dollars through insurance companies that participate in Medicare Advantage. He appears to be capitalizing on the current wave of real interest in finally addressing our country’s dire lack of affordable housing. Jain is proposing that health care providers treat “homelessness” by using a diagnostic indicator that would support billing an ambiguous capitation cost, a cookie cutter price, for all providers, and then Medicare dollars would be sent to private Medicare “Advantage” companies for their financial gain. Paying health insurance companies to house the homeless is a bad idea.
Health care providers treat illnesses and injuries. Doctors and nurses struggle to find time to attend to their patients and also consistently comply with complex documentation guidelines that support accurate coding and billing processes. To suggest that providers also treat homelessness and bill for it, so that Medicare Advantage companies can profit, sounds like nothing short of outlandish greedy profiteering.
Let’s not pretend that doctors and nurses have the time to tackle homelessness. Paying Medicare Advantage plans to house the homeless is an extremely costly and inefficient way to provide shelter to the homeless.
Sincerely,
Mindy Greiling and Valerie Swenson
Former MN Rep. Mindy Greiling and Medical Coder, Valerie Swenson, CPC, both serve on the leadership team of the Roseville Area Advocates for Minnesota Health Plan(RAAMHP,) a chapter of Health Care for All Minnesota(HCAMN.)
Jain apparently is proposing that Congress address the homelessness problem by funneling even more tax dollars through insurance companies that participate in Medicare Advantage. He appears to be capitalizing on the current wave of real interest in finally addressing our country’s dire lack of affordable housing. Jain is proposing that health care providers treat “homelessness” by using a diagnostic indicator that would support billing an ambiguous capitation cost, a cookie cutter price, for all providers, and then Medicare dollars would be sent to private Medicare “Advantage” companies for their financial gain. Paying health insurance companies to house the homeless is a bad idea.
Health care providers treat illnesses and injuries. Doctors and nurses struggle to find time to attend to their patients and also consistently comply with complex documentation guidelines that support accurate coding and billing processes. To suggest that providers also treat homelessness and bill for it, so that Medicare Advantage companies can profit, sounds like nothing short of outlandish greedy profiteering.
Let’s not pretend that doctors and nurses have the time to tackle homelessness. Paying Medicare Advantage plans to house the homeless is an extremely costly and inefficient way to provide shelter to the homeless.
Sincerely,
Mindy Greiling and Valerie Swenson
Former MN Rep. Mindy Greiling and Medical Coder, Valerie Swenson, CPC, both serve on the leadership team of the Roseville Area Advocates for Minnesota Health Plan(RAAMHP,) a chapter of Health Care for All Minnesota(HCAMN.)
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