Tom Sullivan | July 21, 2021
Sachin Jain, MD, opened a homeless clinic in 2001 while he was a student at Harvard University. The clinic operated for three years and Jain continued at Harvard Medical School. Since then, he has served in the federal government as both a founding member of the Center for Medicare & Medicaid Innovation and a senior leader at the Office of the National Coordinator for Health IT, as well as in private sector roles, including chief executive at CareMore Health.
Today, Jain is the CEO of SCAN Group and Health Plan, which established Healthcare in Action, a medical group specifically for individuals in Southern California’s senior population who are experiencing homelessness.
Health Evolution Editor-in-Chief Tom Sullivan spoke with Jain about the grand vision of solving homelessness, how his experience working on the problem earlier in his career informed Healthcare in Action, and the human element necessary when treating one of the hardest populations.
What inspired the Healthcare in Action medical group?
Jain: As an undergrad, I volunteered at a Harvard Square homeless shelter in Cambridge. I worked the post-dinner shift, which was great because you cleaned dishes and ended up speaking with folks. I got to know individuals who were experiencing homelessness and it was striking how many had suffered from homelessness because of health care issues and how much it exacerbated those.
So, I started a homeless health clinic with the Cambridge Health Alliance and established a new homeless health site. Working in the clinic, I learned the basics of supporting that population, how important building trust is and how significant the barriers are because people with mental health and addiction issues are often mistreated in emergency rooms and other care facilities. Then a few years ago when I was at CareMore and looking for an inspirational speaker, I contacted Jim O’Connell, the founder of Boston Health Care for the Homeless Program, and asked him to participate in a plenary fireside chat. While I was interviewing him in front of our 3,000 associates, there was a eureka moment that prospective payment models are a solution to homeless health care because we can allocate investments to avoid ER visits, ICU stays, unnecessary hospitalizations such that Medicare Advantage could be a vehicle for addressing homeless people. We presented it to [then CMS Administrator] Seema Verma and discussed with Brad Smith of CMMI.
Then when I came to SCAN, it was evident that we had to make it real. We just needed to start the work so we decided to build the medical group founded on intensive outpatient management to avoid expensive care. Mike Hochman was a year ahead of me at Harvard Medical School and a key person as I got to know the LA health care community. So we recruited him to lead the group.
Sachin Jain, MD, SCAN Group and Health Plan
For other CEOs who might consider a similar strategy, how does this program function? What is the business model?
Jain: If you’re paying fee for service for homeless health care, you are paying for a lot of services you probably don’t need: emergency visits, psychiatric admissions, ICUs. Using risk adjustment modifier scores from CMS for Medicare Advantage beneficiaries, we calculated that for the 150 SCAN members experiencing homelessness, that score is an average of 2.5, which corresponds to an average per member per month of $25,000. What we’re trying to do is build the Landmark, Aspire or CareMore for people experiencing homelessness with wraparound services to keep them well and own their risk. We jokingly say we’re running it as adverse selection and some people think we’re crazy to try and take care of the absolute hardest people. Sometimes we don’t even have their contact information. But we think we’ve built a model that enables us to do this.
Leading as a CEO when people think what you’re doing is questionable is a challenge we have discussed with Steve Klasko about acquiring a fashion and design school and Nancy Schlichting about hiring a hotel veteran as a hospital executive and others. How do you forge ahead in this instance?
Jain: In LA County, homelessness has always been an issue and it has tripled in magnitude during the time I’ve lived here. When you talk about a crisis in plain sight, it’s hard not to want to be a part of the solution. What motivates me most is the fact that the conversation has gotten so distorted to the point that it’s almost exclusively about housing and housing supply. But the truth is we don’t have a housing supply problem, we have a health care problem in not addressing people with mental health and addiction issues. We haven’t defined homelessness properly. It’s a health care crisis that often times leads to homelessness. So we want to build better clinical models that help people stabilize those conditions because for a lot of these folks their social safety net has disappeared, but when they get help there’s an opportunity to reestablish that social safety net.
You said earlier that people experiencing homelessness can be the hardest to care for or even reach. How will clinicians and staff approach or interact with them?
Jain: My experience in working with people experiencing homelessness is that it requires trust and consistency. Trust takes a long time to build. You have to be present and create a sense of stable and continuous presence. The earliest lesson I learned in homeless health care is that the fastest way to build trust is through an act of unexpected kindness, and in this community that act can be washing their feet. Individuals experiencing homelessness typically do not have good socks or shoes, and often have some sort of a foot condition. Washing someone’s feet slows down the interaction so you can talk to them and build trust — contrast that to the kind of care you and I get, in an office with someone looking at a computer screen for most of the visit.
What do you see as the most substantial risk of this program?
Jain: There’s obviously great financial risk. We believe we can address and solve the problem but it’s also possible that we won’t. I think of this as a grand experiment. It’s the work I’m most proud of in my career to date. We have an opportunity to solve one of the most embarrassing problems in this country. But we’ve built sophisticated financial models to develop the idea that we are doing the right thing. We’re onto something special in using MA to address issues of people experiencing homelessness. And we are not doing this alone. There are a number of founding co-partners. This medical group is not just for SCAN members. It’s payer agnostic and we’ll serve members of other Medicare and Medicaid plans. We’ve already seen a lot of interest and demand from organizations in North Carolina, Las Vegas, Ohio as well as San Diego County and San Francisco County. We are starting in LA and Orange County but it’s just the beginning.
Reflecting back to earlier in your career when you worked with homeless programs, what has changed since then? Not just relative to homelessness but more broadly speaking across health care …
Jain: HRSA has a homeless health care program, which is how a lot of these programs are funded, but they’re living grant to grant or trying to make it work via fee for service. For this population you want a prospective payment model in the global budget, within the regulatory frameworks, to succeed.
More broadly, when I was coming up as a student and a student of health policy, the answer to any problem was always ‘we just need more policies, more policy innovation.’ The interesting thing about having been part of building CMMI and serving in the Obama administration when HITECH and the ACA were being implemented was seeing that almost all of the instruments were created — they were imperfect — but they were created to solve big problems. We have so many great instruments now, new payments models from CMMI, the ACA, innovations through Medicare Advantage, that the pressure is on the delivery system and private sector to make those work. Far too often we look at the easy answers as opposed to really examining a fundamental reengineering to make the system better. That’s the challenge: how to use existing instruments to solve society’s biggest problems. We’re trying to do that with homelessness and home-based primary care. There’s this reflex we as an industry have developed that we just need more policy, but now that we have these policies many organizations are not using them as aggressively or effectively as they could be.