Ethicists walk fine line between the bottom line and admitting homeless

Study shows homeless cost health care system thousands per patient

While the problem of caring for homeless patients might not be equally pressing in rural areas, ethics committees still must come to grips with the challenges these patients pose to the hospitals’ overall bottom line, experts say.

The bottom line, according to new data published in the New England Journal of Medicine,1 is that homeless patients stay longer and cost hos pitals more than indigent patients with homes. But more important to ethics committees is whether these facts should interfere with the plan of care for the patient — regardless of the patient’s personal situation. A recent study by the New York City Health and Hospitals Corporation of nearly 19,000 homeless patients admitted to New York-area hospitals between 1992 and 1993 compared hospital charges and expenses for those patients with 384,000 low-income patients with homes.1

The findings were not promising for the plight of homeless patients: Homeless patients stayed an average of 36% longer than indigent patients with homes. What’s more, the extra length of stay (LOS) alone cost the hospital system an average of $2,414 per homeless patient.

Add this to the already heavy burden of absorbing the cost of indigent care, and the amount is much larger. Major reasons for the extended length of stay, according to the researchers, are legal mandates that require homeless patients suffering from mental illness to be discharged into a supportive environment.

A shortage of available supportive housing and psychiatric beds could make the wait months long. Severe overcrowding in city shelters and lack of low-income housing means that many other homeless patients are kept in a hospital bed until shelter space becomes available, the report states.

Writing in an editorial accompanying the article, Paul Starr, PhD, of Princeton (NJ) University, offers several solutions, but reaching these solutions would require the participation and leadership of state and federal organizations — a task much larger than the abilities of the hospital ethics committee. Starr suggests increasing the minimum wage and relaxing government regulations on the construction of low-cost housing.

"As it is now," he writes. "We continue paying to put the homeless in hospital beds while not providing them with ordinary beds of their own."

Obligation includes unbiased access

While federal regulations create bureaucratic bed nightmares that seem hopeless, there are actions ethics committees can take to curb the problem. Several public hospital systems, for example, are taking a proactive approach to the problem.

Public hospitals face more challenges than their private counterparts. These hospitals and health systems are charged with providing health care to the community at large and are overburdened with the costs of caring for the homeless. But by taking the step of developing health outreach programs, an attempt is made to head off illnesses that land these patients in a hospital bed in the first place.

In addition to the financial concerns of extended inpatient stays, many caregivers also feel that public institutions have an ethical obligation to ensure unbiased access to basic health care. What’s more, the access should be early, instead of waiting until homeless patients are in need of hospitalization before they begin treatment.

"As the public hospital for the county, we are charged with ensuring access to health care to the community as a whole," says Susan Spaulding, MD, director of the Homeless Outreach Medical Services program (HOMES) at the Parkland Health and Hospital System in Dallas.

A few years ago, Parkland began an effort to improve access to primary care and preventive medicine by opening several small community-oriented primary care clinics’ (COPCs) throughout the city. The HOMES program and COPCs are funded jointly by Parkland and the City of Dallas.

Catching problems early

The concept is that by bringing primary care into the neighborhoods where people live, it enables the public to easily access the health system and enables providers to treat health problems before they become so severe they require hospitalization or other, more intensive health care resources, according to Spaulding.

The HOMES program is, in essence, the COPC for the homeless population of Dallas, she says. "It is basically the same thing, it is just that this one is mobile."

Staffed with a full-time internist and a full-time pediatrician, a clinical psychologist, registered dietitian, three nurse practitioners, three RNs, four social workers, an administrative coordinator, and three health care assistants, the HOMES program operates as a six-site health clinic and has two 40-foot mobile medical vans.

HOMES holds 30 clinics a week at 18 different locations throughout Dallas. The clinics consist of three-hour sessions on Monday afternoons; Tuesday, Wednesday, and Thursday evenings; and Friday mornings, says Spaulding.

Services include well-child checkups, immunizations, acute care, referrals to other programs and social services, adult health maintenance evaluations, sexually transmitted disease and HIV screening, acute and chronic disease clinics, and a diabetes education program.

The city originally started a health program for the homeless about 11 years ago, Spaulding says. Originally, the program involved a nurse practitioner going to the city’s shelters to provide basic medical care and making referrals to the hospital.

Seven years ago, Parkland took over administration of the program, expanding it to its current level. It is now one of the system’s COPCs, although it is the only mobile one, Spaulding says.

Physicians in the HOMES program now can do lab work, such as blood testing, for homeless patients. They have a class D pharmacy on both vans, and the physicians can make referrals to specialists at Parkland’s hospital.

"As the county hospital for the Dallas area, they are charged with providing care to the community at large," says Spaulding. "With the move to the COPCs, this was another effort at getting out into the community."

The hospital system doesn’t keep data on which patients are homeless, so there is no accurate way to gauge the financial impact the program has had on the hospital system. Spaulding says, however, the efforts the HOMES staff make at preventive care result in fewer primary care visits to the hospital’s emergency department (ED). "The cost of a visit to the HOMES site is much less than the cost of an average ED visit," she says.

Currently, the project has a budget of $1.5 million, split between city funds and Parkland’s operating funds, she notes.

She admits the hospital system absorbs most of the cost of care, but the system’s overall health is shown by the fact that the hospital has been able to lessen its dependence on the Dallas tax base in the past few years, becoming largely self-sufficient. "That is always a challenge for any public hospital system."

Cooperative agreements are an option

Some hospital systems, however, have developed arrangements with existing homeless health programs, which takes a slightly different approach to solving the problem of providing care to the homeless. In cooperative agreements, a hospital system provides funds and administrative and clinical support to an organization already familiar with the homeless population and set up to handle its specific needs.

The Health Care Center for the Homeless (HCCH) in Orlando, FL, runs a primary health care clinic, dental clinic, vision clinic, wilderness outreach, and tuberculosis shelter on an annual budget of about $500,000. HCCH receives about $750,000 in financial support and in-kind services from three area hospitals: Florida Hospital, Orlan do Regional Health Care System, and Central Florida Health Care System.

"We also have specialists throughout the community who give us two procedures a year, and we make referrals to them," says Paul McGlone, president of HCCH.

When patients need surgery or hospital admission, the hospitals take the case on a rotating basis. The center has more than 9,300 patient visits per year to its primary care clinic at a cost of about $361,000 or $38.00 per patient.

By helping homeless people enter the health care system at a primary health care level, the center has been able to treat acute medical problems before they require a hospital admission, says McGlone.

Most treated as outpatients

A good example is pneumonia. Although in its initial stages, the illness can be treated on an outpatient basis. If left untreated, however, pneumonia can be life-threatening and often leads to hospitalization.

According to HCCH data for 1995, the latest available, the primary care clinic treated 1,379 cases of pneumonia, cellulitis, unhealed wounds, spider bites, and venereal diseases — all on an outpatient basis.

By helping homeless patients manage chronic conditions, such as diabetes and hypertension, the center also has helped reduce visits to area EDs. Many diabetes patients who present at the center are close to requiring hospitalization, with nearly 60% showing blood glucose levels of 300 or greater (normal is 100), according to center data.

In 1995, HCCH treated 247 diabetic patients, with only four patients needing a referral for treatment in the ED.

The center has a full-time clinical staff of one physician, one nurse practitioner, and a paid dental hygienist to manage the cases in the dental clinic. It is heavily dependent on the specialists and other health professionals who volunteer their services regularly, says McGlone.

The primary care clinic volunteers include 43 primary care physicians, five advanced registered nurse practitioners, 22 nurses, and seven front desk (intake) personnel. In addition, there are 77 volunteer physicians who provide specialty secondary care.

"We have one retired physician who comes in and works evenings in our primary care clinic two and a half days a week," notes McGlone.

A retired dentist also comes in and spends one evening a week seeing patients in the dental clinic, he adds. "I think that this is evidence of what can happen when you have everyone working together," he says. "You hear a lot about medical centers and hospitals and how competitive they are, but this is an example of [different systems] coming together to work toward a solution."


1. Salit SA, Kuhn EM, Hartz AJ, et al. Hospitalization costs associated with homelessness in New York City. N Engl J Med 1998; 338:1,734-1,740.