Similar contracts could be structured for SM groups willing to enter into shared-savings arrangements with a third-party payer. Other programs that aim to improve care and lower downstream acute care utilization for high-needs, high-cost patients-such as Landmark Health and Aspire-have utilized shared-savings payment models, whereby providers receive a portion of the healthcare savings they generate, to support programmatic costs. Based on these numbers, a theoretical 15% reduction in ED, hospital, and SNF costs could generate greater than $9000 in savings per patient per year-more than enough to offset program costs. In this cohort, the mean annual cost of care was approximately $69,000 per person, with 87% of costs attributable to emergency department (ED), hospital, and skilled nursing facility (SNF) visits. 2, 3, 4, 5 To estimate the potential for cost savings of an SM program, we conducted an internal analysis of 40 SCAN health plan patients who were dually eligible Medicare/Medicaid beneficiaries and were experiencing homelessness in Southern California. Existing research, albeit descriptive and observational, indicates SM programs hold potential to reduce ED and hospital utilization. While SM programs are costly to sustain, the high rates of acute care utilization for PEH may offer a path for sustainability. Since standard payment mechanisms are inadequate to support such costs, most SM programs rely heavily on charitable funding. An informal poll of mobile SM programs in Southern California, including a program called Healthcare in Action, recently launched by two of the authors (MH and SJ), found SM team panel sizes range from 70 to 200, with an estimated annual per patient cost of $3000–$9000 per year. Nevertheless, SM programs have struggled to spread, presumably due to inadequate primary care reimbursement to support high-intensity SM services. 3, 4 SM clinicians often attribute these successes to the focus on building trust with historically marginalized patients, a common challenge in standard healthcare settings. SM teams have reported successful placement of PEH in transitional and supportive housing, sustained buprenorphine use for opioid use disorder, improved insurance enrollment, and decreased ED visits (75%) and hospitalizations (66%). Though limited and informal, existing literature on mobile SM suggests it is a high-value service. While at first blush such an approach might seem impractical, SM providers report enhanced engagement of PEH, likely by reducing barriers to care and SM’s person-first approach in prioritizing patients’ self-identified needs, experiences, readiness, and well-being. SM services typically emphasize behavioral healthcare, addiction treatment, social services, and immediate physical health needs to a greater extent than primary care in standard medical offices, though programmatic structure may vary considerably across SM settings. 2 Rather than expecting PEH to come to a traditional medical office-or even community-based clinics-SM brings care to patients where they are. The term “street medicine” (SM) describes a mobile approach for delivering medical outreach to PEH where they reside, often in encampments in the streets, as well as in shelters and interim housing units. 1 This article describes how “street medicine” can more effectively meet the needs of PEH, articulates value-based payment strategies that could sustain such programs, and provides recommendations to further evaluate their cost-effectiveness. Consequently, PEH commonly fail to receive basic primary healthcare services, leading to avoidable downstream emergency department (ED) and hospital utilization costing billions of dollars per year. On the provider side, clinicians report that PEH are among the most challenging to care for given their interwoven health and social needs. Traditional medical office settings are often unwelcoming and difficult for PEH to navigate due to social, logistical, and health-related barriers. Yet poor health is both a cause of homelessness and an effect, and the healthcare system is poorly suited for PEH. This epidemic has triggered calls to bolster housing and social services for persons experiencing homelessness (PEH), with less attention to the complex medical needs of these patients. More than half a million people experience homelessness in the USA on a given night.
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