While the virus has traditionally been thought of as a childhood ailment that affects babies, older adults can suffer from it.

This article was published on Wednesday, July 31, 2024 in KFF Health News.

By Sam Ogozalek, Tampa Bay Times

New immunizations are also available to combat respiratory syncytial virus, or RSV, for those at high risk of illness. Although the one-time shots reached pharmacies last year, fewer than a quarter of those 60 or older nationally had been vaccinated as of May.

Even in Florida, not many older adults have gotten the shot yet. That's telling for a place with a high concentration of seniors because, while the virus has traditionally been thought of as a childhood ailment that affects babies, older adults can suffer from it, too. And Florida, with its humid weather, is the nation's ground zero for RSV. Each year, infections typically start in Florida and the Southeast before spreading to other parts of the United States, according to the University of Florida's Emerging Pathogens Institute.

The Sunshine State's RSV season runs longer than anywhere else in the U.S., the institute said. There and in other places with tropical, humid climates, outbreaks can occur sporadically throughout most of the year, according to the institute.

That means RSV season is already underway in some parts of Florida and is coming soon to the rest of the country. Here's what to know about it:

Q: What Is RSV?

The respiratory virus is common but gained more widespread recognition amid the COVID pandemic.

In medical school, many doctors were taught that RSV was an important pediatric illness but not a major issue for older adults, said William Schaffner, an infectious diseases specialist at Vanderbilt University Medical Center in Tennessee.

The pathogen typically follows a seasonal pattern and usually causes mild cold-like symptoms, but it can lead to serious problems such as pneumonia in infants and seniors. It spreads through coughing, sneezing, direct contact, and contaminated surfaces.

An estimated 58,000 to 80,000 children under age 5 are hospitalized each year due to RSV in the United States, and as many as 300 die, according to the Centers for Disease Control and Prevention. Kids at highest risk include premature infants and those younger than 2 with chronic lung disease or congenital heart disease. RSV is the leading cause of infant hospitalization in the U.S.

Outbreaks of the virus can occur in settings like day care and schools.

Federal health officials also estimate that up to 160,000 older adults are hospitalized each year due to RSV and as many as 10,000 die.

For those infected, it can be a "really nasty and long-lasting type of illness," said Nathaniel Hupert, co-director of the Cornell Institute for Disease and Disaster Preparedness at Weill Cornell Medicine in New York City.

In Florida, each of five regions has a slightly different period of heightened transmission. For example, central Florida's runs from August to March.

Individual cases of RSV are not reportable to Florida health officials. Only outbreaks are. For now, RSV activity is steady in the Tampa Bay counties. BayCare Health System has seen "very few hospitalizations, especially for adults at this time," said Laura Arline, its chief quality officer.

Q: What Vaccines Are Available?

In 2023, federal regulators signed off on RSV vaccines from pharmaceutical companies Pfizer and GSK. This year, they also green-lighted a shot from Moderna, which uses mRNA technology, as with its covid vaccine.

They also cleared an immunization called nirsevimab, an antibody drug, for use in babies last year.

Q: Who Is Eligible to Be Inoculated?

The CDC urges anyone age 75 or older to get vaccinated. The agency also recommends that those 60 to 74 at high risk of severe illness get the jab. That includes people with chronic heart or lung conditions and patients at nursing homes or other long-term care facilities.

Unlike with flu and covid, the RSV shot is not an annual immunization. Eligible seniors should receive the vaccine once. The best time to do so is in the late summer or early fall, the federal agency said.

To protect young children, health authorities recommend that pregnant mothers get Pfizer's vaccine sometime during weeks 32 through 36 of pregnancy — with the dose administered from September to January — or that infants be immunized with an antibody drug.

Nirsevimab, developed by pharmaceutical companies AstraZeneca and Sanofi, is recommended for infants younger than 8 months during or entering their first RSV season. Another dose is urged for some kids ages 8 to 19 months who are at high risk and entering their second RSV season.

Nationally, an estimated 24% of those 60 or older reported getting an RSV vaccine during the initial rollout, and an additional 11% said they definitely planned to get it, according to CDC survey data from May.

Considering the lack of a universal health care system, and with many people having no primary care physician, "I think that this is a pretty impressive showing," said Hupert of the Cornell Institute for Disease and Disaster Preparedness.

Q: How Much Do the Shots Cost?

The list price of GSK's vaccine is $280 per dose. Pfizer's is $295 per dose. Moderna's retails for about the same, according to health care company GoodRx.

The amount people pay out-of-pocket is set by their insurance coverage's prescription drug plan.

Under the Inflation Reduction Act of 2022, adults enrolled in Medicare Part D drug plans can receive federally recommended vaccines free, said Centers for Medicare & Medicaid Services spokesperson Lorraine Ryan in an email. If someone with Part D is having trouble obtaining RSV vaccine coverage, they should contact their plan or call 1-800-MEDICARE (800-633-4227) for assistance.

Q: Where Are the Vaccines Offered?

Doctor's offices might stock them, but pharmacies or drugstores administered the majority of shots during the first season of availability.

Schaffner, of the Vanderbilt University Medical Center, said that's because the vaccines are covered under Medicare Part D — not Part B. Many physicians "simply don't deal with" Part D-covered immunizations, he said. Pharmacies do, though.

Q: Why Have So Few People Been Immunized?

Federal health officials last year said all adults 60 or older should have the option of getting a vaccine after discussing it with a health care provider. This is known as a "shared clinical decision-making" recommendation and has since been replaced with the latest guidance for those age 60 and beyond.

Shared clinical decision-making recommendations create financial and logistical barriers that can hinder vaccine uptake, according to the Champions for Vaccine Education, Equity + Progress, a coalition of patient, provider, and public health organizations.

Many physicians didn't know about the shots during the first season of availability and weren't convinced of their importance, so further education was needed, Schaffner added. A lot were cautious, too, he said, because of reports of a rare nervous system disorder, Guillain-Barré syndrome, occurring in a small share of people post-vaccination.

Advisers to the CDC concluded that the estimated benefits of getting an RSV vaccine outweigh the risks.

"Let's see if we can do better this second year," Schaffner said.

This article was produced through a partnership between KFF Health News and the Tampa Bay Times.

Montana's plan is part of a national trend by states to try to cover federal enforcement gaps.

This article was published on Thursday, July 25, 2024 in KFF Health News.

By Katheryn Houghton

Montana is poised to become the latest state to increase scrutiny of how its nonprofit hospitals deliver community benefits in exchange for their tax-exempt status.

Under proposed rules, the Montana Department of Public Health and Human Services plans to collect data on nonprofit hospitals' charitable acts, such as discounting prices, providing health education, or conducting free screenings. Montana officials expect to adopt the new rules in August, but state officials have yet to set standards for exactly what constitutes acceptable giving or how much hospitals must do.

The proposal comes some four years after a state audit found shortcomings in the health department's oversight. The rules largely mirror federal requirements that national health policy analysts said have yet to lead to any meaningful enforcement.

"What is being proposed in Montana doesn't really move the needle," said Kevin Barnett, a researcher with the California-based nonprofit Public Health Institute who has studied hospital community benefits for decades. "It kicks the can down the road to say 'we'll consider this another day.'"

State officials would now be paying more attention, he said, but the impact depends on what they do with the information.

Montana's plan is part of a national trend by states to try to cover federal enforcement gaps. The state would join at least 10 others that require nonprofit hospitals to create a broad community benefit plan and 25 states that mandate the facilities publicly share their financial assistance policies, according to The Hilltop Institute, a think tank at the University of Maryland-Baltimore County.

Policymakers have focused on nonprofit hospitals as a growing number of people in the U.S. struggle to afford medical care and, altogether, owe at least $220 billion in medical debt. The debt disproportionately affects people in poverty and Black people, according to data analyzed by KFF, a health information nonprofit that includes KFF Health News.

States with set giving standards take different approaches. In recent years, California adopted new reporting requirements for hospitals to show how they serve vulnerable populations. Oregon created new rules for when and how hospitals must provide patients discounted care. And five states — Illinois, Nevada, Pennsylvania, Texas, and Utah — have set minimums that hospitals must spend toward community benefits.

Just over half of the hospitals in the U.S. are nonprofits. While each must report the "community benefits" they provide, federal law doesn't specify which services qualify or how much to give. Inconsistent hospital reports make it difficult to distinguish between low and high givers.

Montana's 2020 state audit found that hospitals report benefits vaguely and inconsistently. The following year, a KFF Health News investigation found that, even by hospitals' own reports, some of Montana's richest facilities fell behind the national average in community benefit spending.

A Montana law passed in 2023 requires the state health department to track hospitals' giving and to define standards. The department's proposed rules spell out some requirements, such as calling on hospitals to post financial assistance policies prominently online. But mostly, the list of requirements sets the stage for more to come.

Holly Matkin, a health department spokesperson, said the agency will establish standards that are "fair to all nonprofit hospitals." The state plans to collect data over a three-year period to begin establishing standards in 2026.

The state's proposed rules have some differences from federal requirements, such as mandating hospital-level reports as opposed to systemwide information that covers numerous hospital locations. They also leave room for the state to seek more details about how hospitals provide care at reduced prices, such as the number of people who receive financial aid or the average amount given per person.

But the Montana Hospital Association lobbied legislators against including too many reporting rules, arguing it would increase hospitals' administrative burden. State lawmakers then narrowed the data the state can collect to largely the information hospitals already provide to the federal government. The association supports the state's rules as proposed but has said any state standards need flexibility.

"The truth is that most communities have more health needs than they can effectively address," said Bob Olsen, president and CEO of the Montana Hospital Association. "Models that apply a one-size-fits-all standard on communities take decision-making out of local communities, and have the potential to do more harm than good."

Adam Zarrin, director of state government affairs with the Leukemia & Lymphoma Society, supported Montana's proposal during a June 18 public hearing. But he testified that Montana could do more, such as mandating screening for financial assistance and requiring that hospitals provide it to patients at particular income levels.

"These rules could go even further to provide greater access and protections for Montanans who need and apply for financial assistance," Zarrin said.

Health department officials said they plan to create numerical or narrative standards for judging how hospitals say they've responded to people's needs — or a combination of the two. Officials are still vague on what either standard could entail. But they have said the benchmarks would be set each year based on each hospital's size and patient revenue. Hospitals with operating losses wouldn't have to meet the forthcoming rules.

Ge Bai, a health policy professor at Johns Hopkins University who has long studied hospitals' community benefits, said such standards come with trade-offs. For example, standards that can be met through words rather than numbers might allow large hospitals to pay consultants to window-dress the story of their benefits while smaller systems struggle to show their worth. She said numerical rules, such as spending minimums, could cause some hospitals to slow efforts once they meet the state's requirement.

"It's not perfect," Bai said. "But If we don't do anything, well, that's the status quo."

In 2020, Oregon set minimums for the free or discounted care hospitals must provide, but even with those rules, the state's overall charity care spending didn't increase, Bai said. Last summer, lawmakers there added a new set of rules, including that hospitals must screen patients with large hospital bills to see if they qualify for financial assistance.

California also has implemented a combination of standards. In recent years, the state expanded reporting requirements, mandating that nonprofit hospitals explain the math behind their community benefits tally and detail how they're serving vulnerable populations such as people who are homeless. The state also mandated that hospitals offer discounted care to uninsured patients or some people with costly medical bills.

Even in states like California, it can be hard to see how those policies affect patients who struggle to access care, said Barnett of the Public Health Institute. He said he'd like to see states require hospitals to reduce health disparities with specific outcomes, such as lowering preventable emergency room visits by people from especially poor neighborhoods.

In 2025, California will start requiring hospitals to submit annual reports that include an analysis of access to care and a plan to address disparities. The state is still defining those reporting rules.

Whatever standard states employ, health policy researchers said promoting transparency is key, such as by standardizing reporting rules to provide a clear picture across systems. Bai said Montana's rules are a good first step.

Matkin, from the state health department, said whatever giving benchmarks Montana sets won't be a copy-and-paste of what others have tried. The department plans to create standards unique to Montana.

Katheryn Houghton: khoughton@kff.org, @K_Hought

Large compounding pharmacies are provisioning up to 2 million American patients with semaglutide.

This article was published on Tuesday, July 23, 2024 in KFF Health News.

By Arthur Allen

Pharmacist Mark Mikhael has lost 50 pounds over the past 12 months. He no longer has diabetes and finds himself "at my ideal body weight," with his cholesterol below 200 for the first time in 20 years. "I feel fantastic," he said.

Like millions of others, Mikhael credits the new class of weight loss drugs. But he isn't using brand-name Wegovy or Zepbound. Mikhael, CEO of Orlando, Florida-based Olympia Pharmaceuticals, has been getting by with his own supply: injecting himself with copies of the drugs formulated by his company.

He's far from alone. Mikhael and other industry officials estimate that several large compounding pharmacies like his are provisioning up to 2 million American patients with regular doses of semaglutide, the scientific name for Novo Nordisk's Wegovy, Ozempic, and Rybelsus formulations, or tirzepatide, the active ingredient in Eli Lilly's Zepbound and Mounjaro.

The drug-making behemoths fiercely oppose that compounding business. Novo Nordisk and Lilly lump the compounders together with internet cowboys and unregulated medical spas peddling bogus semaglutide, and have high-powered legal teams trying to stop them. Novo Nordisk has filed at least 21 lawsuits nationwide against companies making purported copies of its drugs, said Brianna Kelley, a spokesperson for the company, and urges doctors to avoid them. The FDA, too, has cautioned about the potential danger of the compounds, and leading obesity medicine groups starkly warn patients against their use.

But this isn't an illegal black market, though it has shades of gray.

The FDA allows and even encourages compounding pharmacies to produce and sell copycats when a drug is in short supply, and the wildly popular GLP-1 drugs have enduring shortages — first reported in March 2022 for semaglutide and in December 2022 for tirzepatide. The drugs have registered unprecedented success in weight loss. They are also showing promise against heart, kidney, and liver diseases and are being tested against conditions as diverse as Alzheimer's disease and drug addiction.

In recent years, the U.S. health care system has come to depend on compounding pharmacies, many of which are run as nonprofits, to plug supply holes of crucial drugs like cancer medicines cisplatin, methotrexate, and 5-fluorouracil.

Most compounded drugs are old, cheap generics. Semaglutide and tirzepatide, on the other hand, are under patent and earn Novo Nordisk and Lilly billions of dollars a year. Sales of the diabetes and weight loss drugs this year made Novo Nordisk Europe's most valuable company and Lilly the world's biggest pharmaceutical company.

While the companies can't keep up with demand, they heatedly dispute the right of compounders to make and sell copies. Lilly spokesperson Kristiane Silva Bello said her company was "deeply concerned" about "serious health risks" from compounded drugs that "should not be on the market."

Yet marketed they are. Even Hims & Hers Health — the telemedicine prescriber that got its start with erectile dysfunction drugs — is now peddling compounded semaglutide. It ran ads for the drugs during NBA playoff games. (According to a Hunterbrook Media report, Hims & Hers' semaglutide supplier has faced legal scrutiny.)

The compounded forms are significantly cheaper than the branded drugs. Patients pay about $100 to $450 a month, compared with list prices of roughly $1,000 to $1,400 for Lilly and Novo Nordisk products.

Five compounders and distributors interviewed for this article said they conduct due diligence on every lot of semaglutide or tirzepatide they buy or produce, upholding standards of purity, sterility, and consistency similar to those practiced in the commercial drug industry. Compounders operate under strict federal and state standards, they noted.

However, the raw materials used in the compounded forms may differ from those produced for Novo Nordisk and Lilly, said GLP-1 co-inventor Jens Juul Holst, of the University of Copenhagen, adding that care must be taken in drug production lest it cause potentially harmful immune reactions.

To date, according to FDA spokespeople, reports of side effects from taking compounded versions haven't raised major alarms. But everyone with knowledge of the industry, including the compounders themselves, worry that a single batch of a poorly made drug could kill or maim people and destroy confidence in their business.

"I liken the compounding industry to the airline industry," Mikhael said. "When you have an airline crash, it hurts everybody."

Warnings From the Past

The industry endured just such a catastrophe in 2012, when the New England Compounding Center released a contaminated injectable steroid that killed at least 64 people and harmed hundreds more.

In response, Congress and the FDA had strengthened oversight. Mikhael's company is an outsourcing facility, or 503B compounding pharmacy — so-named for a section of the 2013 law that set new requirements for drug compounders. The companies are licensed to make slightly different versions of FDA-approved drugs in response to shortages or a patient's special needs.

The law created two classes of compounding pharmacies: The FDA regulates the larger 503B compounders with standards like commercial drug companies, while 503A pharmacies make smaller lots of drugs and are largely overseen by state boards of pharmacy.

The 503A facilities also are producing compounded semaglutide and tirzepatide for hundreds of thousands of patients. Like the 503Bs, these operations take the active ingredient, produced as a powder in FDA-registered factories, mostly in China, then reconstitute it with sterile water and an antimicrobial in small glass vials.

Together, the compounding pharmacies may account for up to 30% of the semaglutide sold in the U.S., Mikhael said, although he cautions that is a "wild ballpark figure" since no one, including the FDA, is tracking sales in the industry.

The compounders say the companies should increase production if they're worried about competition. Like the dozens of other drugs they produce for hospitals and medical practices, the compounders say, the two diet drugs are essential products.

"If you don't want a 503B facility to make a copy, it's pretty simple: Don't go short," said Lee Rosebush, chair of a trade association for 503B pharmacies. "FDA created this system because these are necessary drugs."

Novo Nordisk hasn't specified why it can't keep up with demand, but the bottleneck apparently lies in the company's inability to fill and sterilize enough of its special drug auto-injectors, said Evan Seigerman, a managing director at BMO Capital Markets.

The company announced June 24 that it was investing $4.1 billion in new production lines at its Clayton, North Carolina, site. The FDA last year issued a warning over procedural violations at the site and separate cautions at an Indiana facility that Novo Nordisk took over recently.

Compounding for Dummies

At least 28 companies mostly in China, are registered with the FDA to produce or distribute semaglutide. At least half the companies have entered the market in the past 12 months, driving the raw material's price down by 35%, according to Scott Welch, who runs a 503A pharmacy in Arlington, Virginia.

Compounders can buy powdered semaglutide from some U.S. distributors for less than $4,000 a gram, said Matthew Johnson, president and CEO of distributor Pharma Source Direct. That comes out to as little as $10 per weekly 2.5-microgram dose – not including overhead and other costs.

While Ozempic or Wegovy patients use a Novo Nordisk device to inject the drug, patients using compounded products draw them from a vial with a small needle, like the device diabetics use for insulin.

Some medical practices provide the compounded drug to patients as part of a weight loss package, with markups. Last July, Tabitha Ries, a single mother of six who works as a home health care aide in Garfield, Washington, found an online clinic that charged her $1,000 for three months of semaglutide along with counseling. She has lost 35 pounds.

She gets the drug from Mindful Weight Loss, a mostly telehealth-based operation led by physician Vivek Gupta of Manhattan Beach, California. Gupta said he's prescribed the weight loss drugs to 1,500 patients, with about 60% using compounded versions from a 503A pharmacy.

He hasn't seen any essential difference in patients using the branded and compounded forms, although "some people say the compounding is a little less effective," Gupta said.

There's some risk in using the non-FDA-approved product, he acknowledged, and he requires patients to sign an informed consent waiver.

"Nothing in life is without risk, but I would also argue that the status quo is not safe for people who need the medicine and can't get it," he said. "They're constantly triggered by all this food that's causing their weight to go up and their sugar to go high, increasing their insulin resistance and affecting their limbs and eyes."

Compounding semaglutide is a helpful sideline for pharmacists like him, Welch said, especially given the pinch on drug sale revenue that has led many independents to close in recent years. He figures he earns 95% of his revenue from compounding drugs, rather than traditional prescriptions.

It's important to distinguish compounded semaglutide from unregulated powders sold as "generic Ozempic" and the like, which may be contaminated or counterfeit, said FDA spokesperson Amanda Hils. But since compounded forms of the drug are not FDA-approved, those who make, prescribe, or use them also should have "an increased level of responsibility or awareness," she said.

Corporate Battles

Novo Nordisk and Lilly, in lawsuits each company has filed against competitors, say their own testing has found bacteria and other impurities in products made by compounding pharmacies. The companies also report patent infringement, but compounders, pointing to the FDA loophole for drugs in shortage, appear to have defeated that argument for now.

When the FDA removes the drugs from the shortage list, 503B compounders must immediately stop selling them. Smaller compounders may be able to produce their products for a reduced number of patients, said Scott Brunner, CEO of the Alliance for Pharmacy Compounding, which represents 503A compounders.

The evaporation of the compounded drug supply could come as a shock to patients.

"I dread it," said David Wertheimer, an internist in Franklin Lakes, New Jersey, who prescribes compounded semaglutide to some patients. "People are not going to be able to plunk down a grand every month. A lot of people will go off the drug, and that's a shame."

Arthur Allen: aallen@kff.org, @ArthurAllen202

Healthcare in Action brought in about $2 million in revenue in its first year, $6 million in 2022, and $15.4 million in 2023.

This article was published on Friday, July 19, 2024 in KFF Health News.

By Angela Hart

LOS ANGELES — They distribute GPS devices so they can track their homeless patients. They stock their street kits with glass pipes used to smoke meth, crack, or fentanyl. They keep company credit cards on hand in case a patient needs emergency food or water, or an Uber ride to the doctor.

These doctors, nurses, and social workers are fanning out on the streets of Los Angeles to provide health care and social services to homeless people — foot soldiers of a new business model taking root in communities around California.

Their strategy: Build trust with homeless people to deliver medicine wherever they are — and make money doing it.

"The biggest population of homeless people in this country is here in Southern California," said Sachin Jain, a former Obama administration health official who is CEO of SCAN Group, which runs a Medicare Advantage insurance plan covering about 300,000 people in California, Arizona, Nevada, Texas, and New Mexico.

"The fastest-growing segment of people experiencing homelessness is actually older adults," he said. "I said, ‘We've got to do something about this.'"

Jain's organization three years ago created Healthcare in Action, a medical group that sends practitioners onto California's streets solely to care for homeless people. It has grown rapidly, building operations in 17 communities, including Long Beach, West Hollywood, and San Bernardino County.

Since its launch, Healthcare in Action has cared for about 6,700 homeless patients and managed roughly 77,000 diagnoses, from schizophrenia to diabetes. It has placed about 300 people into permanent or temporary housing.

Street medicine in most of the country is practiced as a charitable endeavor, aimed at serving a challenging patient population failed by traditional medicine, its proponents say. Living transient, chaotic lives, homeless people suffer disproportionately from mental illness, addiction, and chronic disease and often don't have health insurance — or don't use it if they do.

That makes designing a business around caring for them a risk, insurance executives and health economists say.

"It's really innovative and entrepreneurial to take all this energy and grit to try and improve things for a population that is too often ignored," said Mark Duggan, a professor of economics at Stanford University who specializes in homelessness and Medicaid policy. "Financial incentives matter massively in health care. It's everything."

An estimated 181,000 people were homeless in California in 2023 — about 30% of the nation's total. The number living outside, more than two-thirds of California's total, increased 6.9% over the previous year.

The state's leaders, including Democratic Gov. Gavin Newsom, have struggled to make inroads against the mounting public health and political crisis — despite marshaling unprecedented taxpayer resources.

"We have a huge problem on our hands, and we have a lot of health plans and municipalities saying, ‘We need you,'" Jain said.

On the Streets

On a cloudy April morning in Long Beach, Daniel Speller navigated his mobile medical van among the tents and tarps that crowded residential streets, searching for a couple of homeless patients. A physician assistant for Healthcare in Action, Speller said he was particularly worried about the badly infected wounds they developed on their limbs after they used the street drug xylazine, an animal tranquilizer often mixed with fentanyl.

"These wounds are everywhere. It's really bad," Speller said. If infections progress, they can require toe, foot, or arm amputations.

"Man, this one is still so deep," Speller said as he peeled denim pants from the swollen leg of Robert Smith, 66.

After cleaning and wrapping Smith's leg, Speller asked him if he needed anything else. "I lost my food stamps," Smith replied.

Within the hour, Speller's team of social workers and nurses had summoned an Uber to take Smith to a state office, where he received a new CalFresh card.

"I was so scared. I thought I was going to lose my leg before I met them," Anderson said, grimacing as Speller sprayed his leg with antibiotic mist. "These people saved my life."

Anderson reported feeling lightheaded, so Speller asked another team member to use the company credit card to get him a cheeseburger and a Sprite.

Many homeless people languish on the streets, so entrenched in mental health crises or addiction that they don't much care about seeing a doctor or taking their medication. Chronic diseases worsen. Wounds grow infected. People overdose or die from treatable conditions.

Part of street medicine is bandaging infected sores, administering antipsychotic injections, and treating chronic diseases. Street providers often hand out drug paraphernalia such as clean needles and glass pipes to reduce sharing and prevent infections. Perhaps more importantly, these workers build trust.

Getting homeless patients established with primary care doctors and nurses — who visit them on the streets, in parks, or wherever they happen to be — can prevent frequent and expensive emergency room trips and hospitalizations, potentially saving money for insurers and taxpayers, Jain argues. Even though shelter and housing are scarce, Healthcare in Action's goal is to get patients healthy enough to live stable, independent lives, he said.

But that's easier said than done. In West Hollywood that week in April, Healthcare in Action clinical coordinator Isabelle Peng found Lisa Vernon, a homeless woman, slumped over in her wheelchair at a busy bus stop. Vernon is a regular at nearby Cedars-Sinai Medical Center, Peng and her colleague David Wong said.

When Peng and Wong attempted to examine her swollen leg, Vernon shouted at them and declined aid. "Antibiotics aren't going to save my life!" Vernon yelled as a mouse scurried for the potato chip shrapnel at her feet.

They moved on to their next patient, a man they were tracking with a GPS device they sometimes affix to homeless people's belongings. Use of the devices is voluntary. They work better than cellphones because they less often get taken by law enforcement during encampment sweeps or stolen by thieves.

"Our patients really move around a lot, so this helps us go find them when we have to get them medication or do follow-up care," Wong said. "We have already developed rapport with these patients, and they want us to see them."

Growing Revenue

Street medicine teams are in demand, largely because of growing public frustration with homelessness. The city of West Hollywood, for instance, awarded Healthcare in Action a three-year contract that pays $47,000 a month. The nonprofit can also bill Medi-Cal, California's Medicaid program, which covers low-income people, for its services.

Mari Cantwell, a health care consultant who served as California's Medicaid director from 2015 until early 2020, said Medicaid reimbursements alone aren't enough to fund street medicine providers. To remain viable, she said, they need to take creative financial steps, like Healthcare in Action has.

"Medicaid is never going to pay high margins, so you have to think about how to sustain things," she said.

Healthcare in Action brought in about $2 million in revenue in its first year, $6 million in 2022, and $15.4 million in 2023, according to Michael Plumb, SCAN Group's chief financial officer.

Healthcare in Action and SCAN's Medicare Advantage insurance plan generate revenue by serving homeless patients in multiple ways:

• Both are tapping into billions of dollars in Medicaid money that states and the federal government are spending to treat homeless people in the field and to provide new social services like housing and food assistance.
  
  For instance, Healthcare in Action has received $3.8 million from Newsom's $12 billion Medicaid initiative called CalAIM, which allows it to hire social workers, doctors, and providers for street medicine teams, according to the state.
  
  It also contracts with health insurers, including L.A. Care and Molina Healthcare in Southern California, to identify housing for homeless patients, negotiate with landlords, and provide financial help such as covering security deposits.
   
• Healthcare in Action collects charitable donations from some hospitals and insurers, including CalOptima in Orange County and its own Medicare Advantage plan, SCAN Health Plan.
   
• Healthcare in Action partners with cities and hospitals to provide treatment and services. In 2022, it kicked off a contract with Cedars-Sinai to care for patients milling outside the hospital.
   
• It also enrolls eligible homeless patients into SCAN Health Plan because many low-income, older people qualify for both Medicaid and Medicare coverage. The plan had revenue of $4.9 billion in 2023, up from $3.5 billion in 2021.

"There's been an incredible market fit, unfortunately," Jain said. "You can't walk or drive down a street in Los Angeles, rich or poor, and not run into this problem."

Jim Withers, who coined the term "street medicine" decades ago and cares for homeless people in Pittsburgh, welcomed the entry of more providers given the enormous need. But he cautioned against a model with financial motives.

"I do worry about the corporatization of street medicine and capitalism invading what we've been building, largely as a social justice mission outside of the traditional health care system," he said. "But nobody owns the streets, and we have to figure out how to play nice together."

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

Angela Hart: ahart@kff.org, @ahartreports