Changes in Medicaid Utilization and Spending Associated with Homeless Adults’ Entry into Permanent Supportive Housing

Abstract

BACKGROUND: There is growing interest in financing housing and supportive services for homeless individuals through Medicaid. Permanent Supportive Housing (PSH), which integrates non-time-limited housing with supportive services for people who are disabled and chronically homeless, has seen rapid growth in the last decade, but clear evidence on the long-term impacts of PSH, needed to guide state efforts to finance some PSH services through Medicaid, is lacking. OBJECTIVE: Assess changes in Medicaid expenditures and utilization associated with receiving PSH. DESIGN: Cohort study using a difference-in-differences approach. PARTICIPANTS: A total of 1226 PA Medicaid enrollees who entered PSH 2011-2016 and remained in PSH for 180 days or more, and a matched comparison cohort of 970 enrollees experiencing housing instability who did not receive PSH. MAIN MEASURES: Medicaid spending in aggregate, and on behavioral and physical health services; emergency department (ED) visits and inpatient hospital stays. KEY RESULTS: Three years after PSH entry, spending decreased by an average of $145/month in the PSH cohort relative to changes in the comparison cohort (p = 0.046), with the greatest relative spending reductions occurring for residential behavioral health ($64, p < 0.001) and inpatient non-behavioral health services ($89, p = 0.001). We also found relative reductions in ED use (4.7 visits/100 person-months, p = 0.010) and inpatient hospital stays (1.6 visits/100 person-months, p < 0.001). CONCLUSIONS: These results can inform emerging state efforts to finance PSH services through Medicaid. Additional state expenditures to expand financing for PSH services could be partially offset by reductions in Medicaid spending, in part by facilitating a shift in treatment to outpatient from acute care settings.

Trends in Health Service Utilization After Enrollment in an Interdisciplinary Primary Care Clinic for Veterans with Addiction, Social Determinants of Health, or Other Vulnerabilities

“…One hypothesized reason for this pattern is that some patients may require fewer ED services or hospitalizations over time when receiving more preventive services and better chronic care management in primary care. 31 For example, IPC patients taking prescribed or illicit opioids are educated about and offered naloxone overdose kits, which have shown effectiveness in mitigating overdose risk. 32 Likewise, contextual risks (e.g., environment) for patients engaging in high-risk behaviors or demonstrating symptoms of early progressive chronic diseases can be addressed within an integrated care team to avert adverse events.…”

Association of Shelter-in-Place Hotels With Health Services Use Among People Experiencing Homelessness During the COVID-19 Pandemic

“…Other housing interventions, such as permanent supportive housing, have not shown a similar association with ED visits for PEH with prior high use of acute health services, 29 although there is some evidence these programs may reduce acute care use for the general PEH population. 25 , 26 , 37 …”

Implementation and 12-Month Health Service Utilization and Cost Outcomes from a Managed Care Health Plan's Permanent Supportive Housing Program

“…More-recent studies have examined health care utilization and associated costs longitudinally among Medicaid beneficiaries receiving PSH and an observational comparison group in two large systems of care, New Jersey (DeLia et al, 2021) and Pennsylvania (Hollander et al, 2021). Both studies found statistically significant reductions in emergent and inpatient hospital stays while observing an increase in pharmacy spending among PSH recipients.…”

“…Behavioral health tends to be an important contributor of service utilization and costs among individuals experiencing homelessness. For example, behavioral health care costs were the largest driver of spending in the panel study of Medicaid PSH recipients in Pennsylvania (Hollander et al, 2021). As a note of comparison, for the Los Angeles County Housing for Health program, after which this Inland Empire program was modeled in terms of the program eligibility and the supportive housing service delivery model, the posthousing behavioral health service costs were reduced by 26 percent in the treatment group (no comparison group was used) (Hunter et al, 2017).…”

“…We used this information to construct a comparison group, identifying enrollment dates among the comparison group members that were in alignment with high service utilization rates that we observed in the treatment group. Other studies have ignored this in the construction of the comparison group (e.g., Hollander et al, 2021). This makes it harder to identify the program effect, because we must account for the drop in utilization because of the spike prior to enrollment.…”