In this episode, Josh spoke with Sachin Jain, MD, MBA, the President and CEO of SCAN Group and Health Plan. This is the first of two condensed parts of the conversation between Dr. Liao and Dr. Jain, and has been edited for clarity and length.
Joshua Liao: To lead off, can you share a little bit about yourself and how you got to where you are now?
Sachin Jain: I am an internist who is trained in medicine and business. I spent a couple of years in the Obama administration where I was part of the founding team at CMMI (Center for Medicare and Medicaid Innovation) and part of the ONC (Office of the National Coordinator for Health Information Technology) when David Blumenthal was running it. Over the last decade, I have held leadership of two different value web-based organizations, one was CareMore, I was CEO from 2016-2020 and more recently have joined SCAN Group and Health Plan, which is a non-profit organization focused on keeping seniors healthy and independent. We have over four billion in revenues; we serve over 270,000 seniors in CA, AZ and NV, and now have a number of health care delivery entities including myPlace Health which is a PACE program (Program of All-inclusive care for the Elderly), Welcome Health which is a home-based primary care medical group, Healthcare in Action which is a medical group focused on people experiencing homelessness, and another medical group we just acquired focused on palliative care. So, a broad array of experiences trying to make health care better.
JL: I really was excited to hear about this group and focus around unhoused and homeless individuals. It’s something that I see less of, candidly, as I look across the landscape. How did you get to that point and tell me how the work has been going?
SJ: When I was an undergraduate student, I volunteered at a homeless shelter and had the realization that health care is at the center of why a lot of people become homeless. They either become homeless because of an untreated health care issue, or their health care issues become exacerbated because they’re homeless.
A few years ago, I wanted to invite an inspirational speaker to speak to CareMore for our annual retreat and reconnected with Jim O’Connell, the founder of Boston Health Care for the Homeless. I interviewed Jim on stage, and in the course of just talking to him, I realized that there’s this connection between some of the innovations we’re seeing in healthcare payment and total cost of care, and some of what we could potentially do for people experiencing homeless. I thought we should get a Special Needs Plan for people experiencing homelessness, so proposed to CMS something that I have since called HSNP – a Homeless special needs plan, which would create some flexibilities to be able to better serve a homeless population.
Then when I came to SCAN, I thought we can continue to work with CMS and congress to try and get special plan authorities for plans that focus on people who are experiencing homelessness. But in the meantime, there’s an opportunity to take a total cost of care approach to people experiencing homelessness, and look at how we can use a full Medicare Advantage (MA) dollar to better serve this patient population. And when we double clicked on this population, we realized they have RAF (Risk Adjustment Factor) scores ranging in the 2-3 area, which corresponds to annualized payments of $25,000-35,000 to Medicare Advantage plans that serves people experiencing homelessness. Traditionally, these plans lose a lot of money on these populations because they end up in emergency rooms, intensive care stays, and hospital stays. So, the question became: could you take a total cost of care approach to managing people experiencing homelessness and actually take health care to the streets?
We built a street based medical group called Healthcare In Action, we recruited a dynamic CEO in Michael Hochman who built a really great clinical team that, as we speak, is walking the streets of Los Angeles taking care of over 170 patients since January 1. We’re in the process of trying to grow this group right now to serve as many people as we can. We think it’s a big idea: how do you leverage Managed Care to potentially solve the problem of homelessness?
I think one of the bigger issues that we face is that homelessness has been cast as a housing issue. It has become very popular to talk about housing first and innovations to provide people with housing, when in fact I think it has been mischaracterized. I think what a lot of what makes people homeless is untreated health care issues, severe mental illness, addiction, chronic diseases that go under managed. We’re thinking that if we can actually address peoples’ underlying health care issues, then there’s a segment of people that we can then more sustainably house over the long run.
JL: In one of your articles in Forbes, you described that how a person or group defines a problem determines how that person or group solves it. I can imagine someone saying, “we don’t want to medicalize things”. So, what would you say to people who say, “well yes [medical illness can contribute to homelessness], but we cannot medicalize that; we need to put these health care interventions with other supports.”
SJ: We have to tease it out, right? I think there’s a lot of people, myself included, who say we shouldn’t over medicalize social problems. The health care industry is terrible at delivering health care, we shouldn’t suddenly expand the mandate to include a bunch of other things that we’re eventually going to be terrible at.
At the same time, problem definition is the first stage to problem solution. And if you say homelessness is really a problem of dereliction, then you take a law enforcement approach to homelessness; if you take a view that homelessness is a housing supply problem, then you build more housing. At the end of the day, homelessness is all kinds of problems wrapped in one. And all I’m saying, for the benefit of the skeptics, is that there is a non-zero set of people for whom homelessness is really a health care issue.
So, I take the view that a health care intervention is necessary to solve a health care problem. For some number of homeless people, it is a medical issue that has ultimately landed them on the streets. Homelessness, we know, reduces your life expectancy by almost a decade. Homelessness, we know, puts you at higher risk for suffering violence and trauma. I fundamentally believe we have an opporutnity to really rethink our solutions to homelessness by recasting it as being, in part at least, an issue that is grounded in a medical problem at its core.
JL: You highlighted how this is happening under Medicare Advantage incentives, and a lot of the conversations we’re trying to have is to understand that connection.
SJ: I would say we started out thinking about this as a Medicare Advantage experiment. But we’ve actually extended into Medicaid, driven by an ethical imperative. We couldn’t be on the streets seeing patients and then say to then, well we can’t see you because youre on Medicaid and not on Medicare. Many people who are on the streets likely would quality for Medicare through disability, if not through age. We also know that the fastest growing population by age of people experiencing homelessness is older adults, people over 65. There is a lot of Medicare opportunity, but we’re also working in the Medicaid system through our partnership through Molina as well.
JL: The heart of my next question is how these incentives either enable, create barriers to being able to deliver care, or perceived barriers – like “oh, that cannot happen in this payer segment or population because of x,y, z”. What have you seen there that’s fact or fiction?
SJ: So, the fact is, FFS is a hard system in which to operate this. These are resource intensive models. Your average medical practice, depending on the payer mix, age mix, and intensity mix, people are seeing 600 to 2,000 patients annually. We are paneling a nurse practitioner, doctor, community health workers, to teamlets of 250 patients. So, this is a very resource intensive model that we’re still evaluating. Maybe it’s going to be even more resource intensive than that.
The only reason it works is because we’re making a bet that when you take a total cost of care perspective, that investing in intensive outpatient management will lead to lower overall costs, fewer hospitalizations, fewer ER visits, fewer complications from chronic diseases. And that’s and old idea. It’s the foundation of what people originally called managed care, which people are now morphing to call value-based care; if we invest in more of the kinds of services we need upstream, we’re going to need fewer of these preventable low value services long term.
We’re going to find out if that actually works. This is a grand experiment.
I am a super optimist and recently presented this idea to a room of 250 CEOs at a major healthcare conference. I thought I was going to swarmed by people who wanted to join and do this in their communities and figure out how they might be able to do this. Most of what we got was, “good luck, we’re rooting for you” and “let us know how it goes.” Because I think there are people who look at this and say, “this will be nice to try but we’ll see.”
We’re making a big bet that I think is a good one, frankly, based on my experience working with other high risk, high needs populations. Very few people want to go to the emergency room, few people want to go to the hospital, which is the single greatest cost item when you look at any total cost of care perspective. So, if you can avoid those things, you can actually create a lot of margin to do more of the other kinds of things we’re doing. That’s a lot of what we did at CareMore: we invested very heavily in intensive chronic disease management upstream so that people wouldn’t necessarily need to go to the hospital as much.
JL: I appreciate your candor and perception in the room that you were presenting to. I think part of it too is the sense of we’ve been there before. You said it, right? Some of these are not new ideas – we’ve seen this; it’s nothing new under the sun. Are there new things, new approaches, reframing of the problem, that give you optimism that this is different?
SJ: To be clear, I don’t think anyone has done this with the homeless population. I think the “we’ve done this part” is the hard time managing most high need populations. This is the highest cost, highest need group of patients, so that’s where the “good luck” piece comes from.
I think a couple of things are new. One is technology. We are exploring innovative uses of technology to stay close to patients. We started out the group with me launching the most vocal objections to this, that we’d give cell phones to many of our patients. Turns out, for most patients, cell phones just become currency. They get traded for other things, they get sold, or they get lost. But there is a small subset of patients where you want to give folks that kind of technology.
There’s the opportunity to give folks remote patient monitoring tools. Is there a device or a tile that you can attach to them so that you can find them? I think that technology may enable us to keep track of patients in ways, provided they consent to it, that allow us to stay close to patients who are otherwise very difficult to find.
The third thing is this marriage of managed care plus street medicine, which has just never happened before. There’s been street medicine. But then there’s applying the principles of managed care to this population, intensive case management, care management, community health workers, focused pharmacy management, intensive behavioral health management; the kinds of things that historically have been given in pieces to this population, all being given together, might make a big difference. That’s what we’re betting on.