Health Care Spending and Use Among People Experiencing Unstable Housing in the Era of Accountable Care Organizations

Katherine A. Koh
Melanie Racine
Jessie M. Gaeta
John Goldie
Daniel P. Martin
Barry Bock
Mary Takach
James J. O’Connell
Zirui Song
Peer-Reviewed Article
February 2020

When designing alternate payment models such as accountable care organizations (ACOs) to improve care for vulnerable populations, it is important to understand the impact that social determinants of health have on health care use and spending. This study used Medicaid claims data of individuals continuously enrolled in the Boston Health Care for the Homeless Program and compared their results to Medicaid beneficiaries with stable housing.

Individuals experiencing homelessness had spending 2.5 times higher than the comparison Medicaid population ($18,764 vs $7,561 per person per year averages), with greater spending on outpatient care (including emergency department care), inpatient care, and prescription drugs. This study also noted fewer psychiatric office visits among individuals who have experienced homelessness, which could be due to difficulties engaging with providers because of extensive trauma histories, inability to attend regular appointments, or a lack of psychiatrists for this population.

Massachusetts Medicaid adjusted capitation rates for homelessness based on an annual estimated spending difference of $550 per person, which is about one-eighth of the actual spending difference observed in this study. This analysis, which sheds light on how people experiencing homelessness use health care, can help inform the design of Medicaid alternative payment models.

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