MINNEAPOLIS — Jerome Pate, a homeless alcoholic, went to the emergency room when he was cold. He went when he needed a safe place to sleep. He went when he was hungry, or drunk, or suicidal. “I’d go sometimes just to have a place to be,” he said. He made 17 emergency room visits in just four months last year, a costly spree that landed him in the middle of an experiment to reinvent health care for the hardest-to-help patients here in Hennepin County.
More than 11 million Americans have joined the Medicaid rolls since the major provisions of the Affordable Care Act went into effect, and health officials are searching for ways to contain the costs of caring for them. Some of the most expensive patients have medical conditions that are costly no matter what. But a significant share of them — so-called super utilizers like Mr. Pate — rack up costs for avoidable reasons. Many are afflicted with some combination of poverty, homelessness, mental illness, addiction and past trauma.
A patchwork of experiments across the country are trying to better manage these cases. The Center for Health Care Strategies, a policy center in New Jersey, has documented such efforts in 26 states. Some are run by private insurers and health care providers, while others are part of broader state overhaul efforts. The federal government is supporting some, too, through its $10 billion Innovation Center, set up under the Affordable Care Act. They raise a new question for the health care system: What is its role in tackling problems of poverty? And will addressing those problems save money?
“We had this forehead-smacking realization that poverty has all of these expensive consequences in health care,” said Ross Owen, a county health official who helps run the experiment here. “We’d pay to amputate a diabetic’s foot, but not for a warm pair of winter boots.”
Now health systems across the country are trying to buy the boots, metaphorically speaking. In Portland, Ore., health outreach workers help patients get driver’s licenses and give them essentials, such as bus tickets, blankets, calendars and adult diapers. In New York, medical teams are trained to handle eviction notices like medical emergencies. In Philadelphia, community health workers shop for groceries with diabetic patients. “This is a holy grail in research right now,” said John Vu, a vice president at Kaiser Permanente, one of the largest insurers and care providers in the country. Kaiser has about two dozen projects across the country, including in Denver, where medical teams screen for food insecurity.
Here in Hennepin, a fist-shaped county that encompasses Minneapolis, the pilot program is focused on about 10,000 people — mostly men of color, all poor, some homeless — who got covered when the state expanded Medicaid under the Affordable Care Act. It is paid for with state and federal Medicaid dollars and run by the county government and the safety-net hospital. The aim is to fix patients’ problems before they become expensive medical issues, so the county put its social services department to work. Its workers help people get phones and mailboxes, and take care of unpaid utility bills that otherwise could lead, for example, to insulin spoiling in nonfunctioning refrigerators. The project has even invested in a place where inebriated patients can sober up instead of going to the emergency room.
The idea — to eliminate avoidable hospital use — went against years of economic habit. Hospitals make money by charging per visit and procedure, and fewer of both would dent revenues. So the state offered a carrot: The hospital, Hennepin County Medical Center, a series of gray buildings and glass walkways, would be paid a fixed amount per patient and it would get to keep the money even if patients did not show up, or used less medical care than was paid for. The pilot program, meanwhile, would work on caring for patients in places outside the hospital that are cheaper.
The arrangement, a stark departure from past practice, is increasingly common across the country, part of the changes wrought by the health care law. The federal government has made similar deals with health systems for Medicare patients. Some early experiments have found little or no savings in the short term. But in Hennepin County, medical costs have fallen on average by 11 percent per year since 2012 when the pilot program began, enough to keep it going and the hospital involved. Some of the biggest cost reductions were among the more than 250 patients who were placed into permanent housing.
The future of such efforts is uncertain. For programs that work to actually take root, more states and insurance companies may need to expand what they are willing to cover, for example, housing assistance, said Allison Hamblin, an expert at the Center for Health Care Strategies. And it is unclear if private health systems — which have little experience in taking care of social needs and still make most of their money per procedure — will be as enthusiastic as Hennepin County Medical Center.
“We often hear comments that amount to ‘Are you asking me to fight the war on poverty?’ ” said Kelly W. Hall, a senior vice president at Health Leads, a nonprofit organization that helps medical teams connect patients to social services. “But doing nothing is ‘don’t ask, don’t tell’ when it comes to the realities of patients’ lives. People aren’t comfortable with that either.”
Mr. Pate, 51, came to the Hennepin County hospital’s emergency room last summer complaining of chest pains and thoughts of suicide. His arrival flickered on the screen of a social worker, Cerenity Petracek. She marched out to the emergency room to meet him. “I was thinking ‘Who is this person?’” Mr. Pate recalled, noting that she was not wearing a doctor’s coat. “How’s she supposed to help me?”
She spent over an hour with him and learned that he was homeless and addicted to cocaine and alcohol. She called around, found a treatment program that would accept him, helped him fill out the paperwork and then put him in a car to make sure he got there. A doctor later diagnosed a major heart blockage.
For the hardest-to-reach patients, there are outreach workers in the community. Such positions have been rare in health care because neither Medicare nor Medicaid would cover them. But the Affordable Care Act has opened up new ways to do so. On a frigid morning in February, Prugh Jose, 42, a soft-spoken homeless man suffering from alcoholism and anxiety, called T.J. Redig, an outreach worker who was part of his medical team. Mr. Redig — who wears stylish wool hats and writes novels in his spare time — has a friendly, easygoing manner that earned Mr. Jose’s trust.
Mr. Jose needed to get to the clinic for an appointment about his seizures (from a head injury on a construction job) but had forgotten the time for it. He had not eaten since the previous morning. His ex-wife offers him a couch when he can contribute food, but he had none, and spent the night outside. “It was cold last night, Prugh,” said Mr. Redig, 29, steering his dented green Pontiac onto the Interstate. He has even picked up Mr. Jose from the highway overpass where he panhandles. “Yeah, really cold,” Mr. Jose said. “I went to see my buddies and stuff but no one opened up.”
By the time Mr. Jose got to the clinic, he had missed his appointment. But he was gaining things that could help prevent an emergency later. A community health worker gave him a bag of food: frozen chicken, cereal and canned fruit. The receptionist handed him apple juice, which he used to take anti-seizure pills. “Better,” he said, after a long swig.
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