PHILADELPHIA - Purvis Wright's health, and life, were spiraling out of control.
Wright went to the hospital in July 2018 after a spate of blackouts and throwing up blood. "It was all downhill," Wright said this month. "I wound up with my eight or nine different sicknesses all at once."
After a long stay at Einstein Medical Center Philadelphia, Wright tried going home that September, but the West Oak Lane house where he had an apartment had been sold and all his belongings were gone. That setback forced Wright, 62, onto an odyssey of depending on siblings and homeless shelters for a roof and a bed.
Things started looking up in November, when Cynthia Brown, a community health worker with Wright's Medicaid plan, plucked Wright out of the swirling chaos and steered him toward a new housing program from UnitedHealthcare that the world's largest health insurer was starting in Philadelphia for some of its homeless, chronically ill members.
That program, now in a dozen states, is part of a growing effort over the last decade to help patients struggling with homelessness, poverty, and violence, factors that have been recognized as powerful forces causing, or exacerbating, poor health.
"Many of the people we serve," said Allison Davenport, chief executive of the Medicaid plan, UnitedHealthcare Community Plan of Pennsylvania, have "experienced such instability that their health care becomes intractable. It compounds, it compounds, it compounds and they can't address that in a completely unstable situation."
In Philadelphia, about 400,000 people live in poverty, a stepping stone to chronically poor health and one that makes the city ripe for such interventions as the one UnitedHealth has brought here. For insurers, it is a matter of money, too, when poor health forces such patients to visit emergency room more frequently, costing tens of thousands of dollars.
Since 2016, Pennsylvania's Department of Human Services has announced at least $8.8 million in grants to nonprofits to address social factors that make it hard for the 320,000 Medicaid beneficiaries in North Philadelphia to stay healthy. No rigorous system for evaluating those efforts has been established.
A lot is riding on such experiments as the one by UnitedHealth, because the sickest 1% of the population accounted for 22% of $3.3 trillion in national health-care spending in 2016, according to a federal estimate.
UnitedHealth's housing program, called myConnections, was founded by Jeffrey Brenner.
This is not the first time Brenner, who worked as a family physician in Camden for years starting in 2000, is attempting to tackle such intractable issues as homelessness that contribute to poor health, and high costs.
Brenner gained national renown in the early 2010s for his work at the Camden Coalition of Healthcare Providers, a pioneer in the use of data to track complex patients. A 2011 New Yorker article described their work as "revolutionary" in its ability to trim the cost of health care for "super-utilizers."
Before leaving Camden for UnitedHealthcare in 2017, Brenner invited researchers from Massachusetts Institute of Technology to study the effectiveness of the coalition's program, which focused on coordinating care, helping patients with complex conditions navigate health-care services, and helping them connect to social services.
The study, published last month, brought disappointing news. It found that patients - with at least two chronic conditions - adopted by the Camden Coalition went back to the hospital just as often as patients in a control group who received no special treatment after a hospital discharge.
Given Brenner's prominence, the results received national attention. Still, declaring that these patients are just too hard to help without first solving poverty and other deep-rooted social ills would be precisely the wrong conclusion, said Shreya Kangovi, a professor at the University of Pennsylvania's Perelman School of Medicine.
"These are hard problems to solve. They are every bit as hard problems to solve as cancer or diabetes," said Kangovi, the founding executive director of the Penn Center for Community Health Workers, which develops methods for improving the health of low-income populations.
"They are going to require the best available science, just like we need science and we need a lot of efforts and it's going to take multiple shots to cure cancer," said Kangovi, whose community health worker program was recently shown to save $2.47 for every dollar it cost.
At the Camden Coalition, as early as 2015, it was clear that housing, foremost, but also mental-health and addiction-treatment services were crucial missing pieces of care, according to Kathleen Noonan, who took over as the CEO in 2018. That, according to Noonan, partly explains the poor results from the MIT evaluation, which started in 2014 just as the opioid crisis hit.
Brenner said he spent his last two years at the Camden Coalition pushing for a model called Housing First, which takes participants off the street and puts them in an apartment without demanding two or three years of perfect behavior before getting permanent housing.
The same rigorous study methods applied to the Camden Coalition have shown repeatedly that providing housing and case management reduces the amount of time spent in the hospital and the number of visits to the emergency department.
Brenner, who lives in Lansdowne and is senior vice president for UnitedHealthcare Community & State, brought that focus on housing to his new employer, which is based in Minnesota.
Every week, Brenner said, his staff would review records for Medicaid members in markets where the program is active, looking for homeless patients, whose medical bills in the last 12 months have cost the insurer at least $50,000, primarily due to avoidable hospital admissions, emergency room visits, and nursing home stays.
"Also, there has to be a plausible exit strategy - you can imagine how the person might be able to move on," Brenner said. He makes an exception when he finds homeless people with end-stage cancer. "I'm making them an automatic approval. It's kind of mind-blowing," he said.
The program is designed to get most participants into permanent housing in a year, Brenner said.
UnitedHealth's nationwide goal by the end of this year is to house "more than 350 Medicaid members with extreme social, medical, and behavioral complexities."
In Philadelphia, UnitedHealth has about 57,000 Medicaid members. It has set aside 10 apartments for the program on the campus of Germantown Home, a nursing home in Mount Airy. So far, six of those apartments have been filled.
Nationwide, Brenner said, the insurer pays in the range of $1,200 to $1,800 a month for rent and wraparound services provided by a vendor, which is NewCourtland Senior Services in Philadelphia. Depending on the person, the wraparound services include help with transportation, food stamps, and Social Security benefits.
UnitedHealth has not conducted a full-scale scientific study of the program's results yet, but it gave an example in a presentation of a patient who was costing an average $20,400 a month before the insurer intervened. Now, that patient has an average monthly medical cost of $400, excluding housing expenses.
Wright, who grew up in North Philadelphia near the intersection of Germantown and Lehigh Avenues, now lives in one of the apartments on the Germantown Home campus. "When I came here, I didn't leave here for a week," said Wright, who moved in the day before Thanksgiving. "When I left, I left to go to my doctor's appointment."
It's too soon to say what the future holds for Wright, who said his main health problems now are "blood clots and the blood pressure in the heart," but he described the help from UnitedHealth and NewCourtland employees as a blessing.
"If it wasn't for them, me and a whole lot of other people that's here, we would be in trouble," he said.
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