Let's Talk HIV: Street Medicine

Anna Person: [00:00:14] Hello and welcome! We are excited to welcome you to the next installment of HIV Medicine Association's podcast series, Let's Talk HIV: Why Medicaid Matters. I'm your host, Dr. Anna Person, an infectious disease doctor at Vanderbilt University Medical Center and HIVMA Chair Elect. So this podcast series began last year, and it really delves into both the emerging threats to the Medicaid program, as well as opportunities to strengthen the program and how infectious disease and HIV health care professionals can support Medicaid as really a critical safety net for people with HIV. We're really excited about this episode. For this episode, we're going to talk about the opportunities for expanding access to HIV and other infectious disease services in the Medicaid program, by making it easier to pay for services delivered to people on the street through an intervention called street medicine. And to do that, we have two guests with us today. Dr. Nathan Nolan is an infectious disease physician at the Saint Louis VA in Washington University in Saint Louis and is the founder of Street Med STL.

Nathan Nolan: [00:01:28] Hi there.

Anna Person: [00:01:28] And then Chris Menschner is the director of complex care programs at the Center for Health Care Strategies.

Chris Menschner: [00:01:36] Hi, Anna. Grateful to be here.

Anna Person: [00:01:38] We are so happy to have both of you here. Let's start with some background, and I'll turn it to you to kick us off on this question. Dr. Nolan, can you just orient us to what exactly is street medicine and why it's an important intervention for people with HIV?

Nathan Nolan: [00:01:56] Love talking about this because I think it's a way to expose the audience to a model of care that I think is becoming increasingly relevant. Street medicine is essentially the act of providing health care in what I call non-traditional settings. So outside of traditional hospitals and clinics. The motto of this street medicine institute is to go to the people. And that is quite literally what street medicine is. It is trying to leave behind institutions that might be intimidating to individuals or might have barriers for individuals, and it's trying to attend to health care needs and do outreach medical care to people that otherwise wouldn't be making it into care. Street medicine is critical for people living with HIV and people at risk for HIV. We know that housing status is something that is intimately tied to virologic suppression. We also know that HIV has this bidirectional relationship with homelessness, in that people who are unhoused have an increased risk of being subsequently diagnosed with HIV, and people living with HIV have a risk for becoming unhoused or housing unstable. And so street medicine really is a mechanism to try to reach individuals who may otherwise be falling through the cracks.

Anna Person: [00:03:13] Street medicine really sounds like a powerful way to meet individuals where they're at, and provide care to folks who might not be able to access care through more traditional delivery sites. I'm curious, Dr. Nolan, what are some of the challenges you've seen with scaling up of street medicine?

Nathan Nolan: [00:03:31] Well, that's a complicated question, but street medicine, as one of the founders, Jim O'Connell describes it, is intentionally inefficient. It is resource intensive for individuals, and it is hard to help health systems or health care payers see that that upfront investment really is worthwhile longitudinally because it costs money, it takes time and it's a very relationship based model of care. I'll tell you that there are patients that I've been caring for that took us years to finally get stably housed. Took us years to get stable on medications. We have to build relationships. We have to work with them on many factors in order to get them kind of re-engaged in care, get them on medications. And when funders or hospital systems are looking at the economic value of these interventions, they're often looking at this in a much shorter time frame than the care we're actually providing. This may be years long interventions in order to help one individual. The scalability of this is difficult for a lot of reasons. One is variable coverage and reimbursement. So a lot of street medicine programs are dependent on funding, either from hospital systems or from state payers, or sometimes from other means like managed care organizations. That coverage is variable. As we see with recent changes in how Medicaid is going to be administered, that may change.

Nathan Nolan: [00:05:04] And it makes it very hard to predict year to year how much funding you're going to have and how to keep this program running in perpetuity. I think the bounds of what you offer as a street med program also is difficult to navigate. Are you trying to be a patient centered medical home? Are you trying to essentially reach individuals and then link them back to a more permanent clinic location? What services do you want to provide? Are you going to do just HIV services? Are you going to try to be primary care or you try to also provide substance use services? And then I think there's variable definitions and practices about what street medicine truly is. While there are some formal definitions, I think each street medicine program kind of takes that and modifies it to their own needs. And so some people may go out with a mobile vehicle, some people may purely be out with backpacks on the street. Some people may think that low barrier clinics within other settings, such as harm reduction organizations, constitute something similar to street med. And personally, I think those all constitute that. But it makes it hard to measure, and it makes it hard to know where the bounds of street medicine start and stop. And that sometimes makes it hard to scale.

Anna Person: [00:06:14] That's really helpful to understand. Both the overview of street medicine and the many different, you know, shapes that it can take, and then some of the challenges in really expanding it. You mentioned financing. So turning to you, Chris, now to pick up on the financing and coverage challenges that Dr. Nolan touched on. We know this has been a conversation in states and at the level of the federal government, and that there have been very recent policy changes that may make it easier to get street medicine covered by Medicaid. Can you give us a rundown of where things stand right now?

Chris Menschner: [00:06:52] Sure, sure. Important question. Some of the good news on street medicine coverage is that a lot of forms of it, I guess you could say like typical services that would be provided in a street medicine context to people experiencing homelessness, like wound care, infectious disease testing, you know, certain forms of substance use, care or counseling, are reimbursable under existing Medicaid authority and have been for a long time. One of the, you know, really frankly, game changing policy developments in recent years was back in 2023 when the Centers for Medicare and Medicaid Services developed place of service code number 27. That allows providers to provide an bill for services that are provided on the street and outside of traditional settings, as Dr. Nolan was talking about. That's really been a game changer. So that opens up the door to billing for services provided again on the street that were not billable in non-traditional settings, including the street previously. So place of service code number 27. There's a number of other mechanisms that can can facilitate Medicaid payment and financing for street medicine services that providers can pursue in partnership and collaboration with state Medicaid leadership. 

Chris Menschner: [00:08:01] One form are state plan amendments. When states, just quick background on the Medicaid front, states must periodically submit state plans to the federal agencies, CMS, in particular, to have approved what they plan to offer and would like to be reimbursed for in their Medicaid program so they can amend those plans and include street medicine. Of course, they're subject to federal approval, but that's one mechanism. There's another mechanism called 1115 waivers, where states can request the waiving of certain regulations or rules in the Medicaid program to essentially like test and pilot new approaches. I mentioned the POS code, and there's also a new policy change that allows FQHCs to include street medicine and what's called their scope of project, essentially like similar to the Medicaid state plan, where they would need to submit to federal authorities, you know, kind of what's in the scope of services that they're going to offer. And recent policy changes have allowed for street medicine within FQHC scopes of project, a number of different mechanisms to pursue sustainable financing for street medicine services.

Anna Person: [00:09:08] So that's really encouraging to hear all that. And it sounds like it's a good opportunity for us to get more involved with our state Medicaid programs and hopefully influence some of the changes that you mentioned. I have to ask, and I'm sure a lot of listeners are thinking about this, given the budget reconciliation bill that was signed into law just a few weeks ago, that cuts Medicaid funding by $1 trillion over ten years. And, of course, the decision of the administration to rescind its guidance on health related social needs services. How do you think all of these coverage mechanisms might change moving forward, given what has just happened in the last few weeks?

Chris Menschner: [00:09:51] Yeah, certainly important to consider in some ways. It's tough to say. I think somewhat obviously there will be restrictions or limitations or reductions on access and eligibility, unfortunately, given the cuts and some of the policy changes. Our hope, of course, is that these mechanisms will not change. Um, especially the place of service code being such a game changer. I will say that, you know, while there hasn't been any formal or specific guidance or rule change on 1115 waivers from federal agencies that the ones that are being approved, it seems to be like there's a tightening on that as of late. So I think the prevailing recommendation might be to pursue it through a state plan amendment. I think there's, you know, that's probably a better bet at this time than 1115 waivers. And again, like, there's been no, you know, specific mention of the place of service code going away. And again, our hope is that that stays because it's really opened the door to a lot of Medicaid financing. I will say to, and folks in the HIV community are no stranger to this, like being very collaborative and partnership oriented in terms of braiding and blending funding sources together to stand up important services is probably more important now than ever with theoretically reduced Medicaid eligibility and access. So just, you know, being more creative around partnerships and again, like braiding and blending funding, grant funding, whether that's state any level or federal funding or philanthropic funding. So it's a challenging time, but we're hopeful on some fronts.

Anna Person: [00:11:22] I can appreciate that. Thank you for those points. It's clear, Chris, that Medicaid has a really important role to play here and that even with some movement to increase coverage for street medicine over the past several years, it does seem clear that federal funding cuts are going to make the road ahead a little bit harder. So I'm eager to hear from you, Dr. Nolan. Tell us what would increase Medicaid coverage for street medicine services mean for your clinic?

Nathan Nolan: [00:11:50] Yeah. So that's a great question. We had been having some high level conversations about 1115 waivers in our state. I think those conversations are a bit on pause as we try to figure out how to navigate this new landscape, post the big, beautiful bill. Right now, we don't bill any Medicaid for the services we provide. I would say in talking to street medicine organizations across the US, that it's very variable about whether or not they do bill Medicaid. I will say that even though we have the CMS point of service code, it's also variable about whether or not states enact that code for billing within their state. So there are some states, like California, that have been very forward looking and have very robust street medicine programs. I would say there are other states that are less well developed and have less well developed funding models.

Anna Person: [00:12:43] We also know that other federal policies and funding can also impact street medicine programs. And this is sort of late breaking news for us. We're recording this on July 25th. And just yesterday, July 24th, the White House issued an executive order that, well, it was not geared toward street medicine specifically. It can certainly make it harder for these programs to exist. The executive order embraces, really a heavy law enforcement approach to homelessness and drug use and sort of disavows harm reduction strategies. So this is obviously still quite new, and we'll have to see how the administration actually implements this executive order. But Nathan, you know, again, turning to you, do you have any immediate thoughts or reactions as to how this executive order might impact your program and the people that you serve?

Nathan Nolan: [00:13:34] I have a lot of thoughts, so I appreciate the opportunity to speak about this. I think where I would start is to say that I understand that there is often a tension between communities and the unhoused people that live within those communities. Many of us want to live in communities where we don't have a number of people who are living on the streets. I think the intent of this, or at least the proclaimed intent, was, how do we help get people off the streets? I think the strategy that's being endorsed is not the right one for a lot of reasons. You know, one of the things that at least reading a bit into this executive order is a movement away from housing first strategies, which have really been a cornerstone of evidence based care for people who are unhoused. I just want to take a second to talk about that. So in housing first strategies, the idea is how do we move people off of the street and then start to navigate some of the other comorbidities that they have. And that may be things like substance use, mental health concerns, or other medical concerns. In a way, I think of housing first, as you throw out a buoy to someone and you pull them to shore before you try to teach them how to swim. The language in this executive order really is moving towards something like a sobriety first, or people have to be in some sort of recovery before they get housing. And again, that's like when someone's out drowning, you're trying to teach them how to swim. And it's very hard to start on medications for substance use if you don't even have a stable place to sleep at night.

Nathan Nolan: [00:15:05] When we think about our population, people living with HIV. If you don't have a stable place to store your medications, if you don't have regular transportation, if you don't have regular food, because some of the medications we use are dependent on if someone has a regular meal, then we're really setting those those individuals up for failure. I want to highlight one other issue that I see not infrequently, and that's how the criminalization of homelessness impacts our ability to deliver care. It's very unfortunate and heartbreaking when I show up to someone's previous place of residence, where their tent was, where they were staying, and I come to deliver their medications and they're no longer there. And if you don't have a phone, if you don't have an address, if you don't have internet and email. Like how do I find that individual? So these may have been critical medications, that may have been their HIV medications, their inhalers for their COPD their medications for substance use disorder, and now I'm just left with a bag of medications because the encampment was swept or police came by and said you have to move. What we really need when trying to provide care for these individuals is the ability to develop a longitudinal relationship, and that requires some level of stability and an otherwise very unstable life circumstance. And by criminalizing these individuals, you're just adding a layer of complication that really prevents us from being able to make meaningful impacts in their life and move them forward to stability and hopefully more permanent housing down the road.

Anna Person: [00:16:32] Yeah, that's really helpful. The listeners can't see, but I've been nodding vigorously through everything that you said. That's a really important perspective, I think, on some fast moving federal updates. And we'll have to wait and see how this executive order impacts federal funding and programs. As we close out our discussion, I'd like to turn to each of you to provide some insights into how HIV providers can weigh in on these issues, and specifically, how they can support Medicaid coverage of street medicine programs. And Chris, I'll start with you. You've outlined some of the opportunities out there, but how can HIV providers such as myself, how can we help encourage their states and MCOs to adopt these coverage changes?

Chris Menschner: [00:17:13] Yeah, I think providers, physicians in particular, and physician leaders even more so have a really critical role to play, especially during these times in this policy context, particularly in partnering and collaborating with state Medicaid leadership. This may be foreign to some of the listeners, maybe not so much for others, but I can say is a former state official not a medicaid state official, but a public health official. Um, partnership and collaboration from faculty at universities or heads of different membership organizations like HIVMA and IDSA. When I was approached by them with ideas for innovation, how to deal with kind of stubborn and long standing issues in the field, I always welcome them with open arms. I mean, providers and again, physician leaders in particular, have such incredible subject matter expertise to share on the clinical aspects for caring for the population that we're talking about today. But also on the engagement piece. Dr. Nolan touched on this, I think it's so important, that street medicine providers that have been out there for a while and have had a successful experience have had to inherently develop that expertise on the connection front. And there's a lot that goes into it. It's really the foundation of any successful clinical relationship. So I think there's a lot to be learned on that front and how to build that into Medicaid policy and financing structures.

Chris Menschner: [00:18:33] You know, there are some pretty specific and discreet ways that providers can engage in some of this collaboration on the crafting of state plan amendments and 1115 waiver requests. Pilot initiatives, serving on work groups or task forces, testifying at budget hearings. You know, when it's kind of budget season in a given state. And one thing, too, that I wanted to make sure to touch on in this context is that, as Doctor Nolan noted early on in the conversation, street medicine can be and is often like a resource intensive intervention, but I think the cost savings on the back end are really important to note. It's hard to make that case without, you know, clear and specific data on a on a specific street medicine intervention. But we know very much so that averted. You know, Ed visits save a lot of money for health systems and payers averted cases of HIV and hepatitis and other communicable diseases, save a lot of money. And also, of course if people are healthier and more well, and, you know, able to participate in employment and other activities in society, there's, you know, a real benefit there economically and beyond. So I think there's a like kind of a growing case to be made around the cost effectiveness of street medicine. And it might be a little bit longer term, but important to note nonetheless.

Anna Person: [00:19:46] That's really great to mention. I appreciate your thoughts. Dr. Nolan, any closing insights you can share with us about how you've advocated for street medicine in your state?

Nathan Nolan: [00:19:56] As health care providers, we have this opportunity to not only speak to policy, but to speak to the impact in the form of patient stories. I find that being at that interface of thinking about high level policy decisions, but also how does that impact this individual in front of me and being able to tell those stories to lawmakers, to policymakers, I think, really provides a way to characterize these problems in a way that people can actually understand and not just see these as numbers on a piece of paper. I'll leave you, just maybe, with one story and an example of how this model of care works. I had a patient that I was caring for who had HIV and advanced psychosis, and he was kind of just left to his own devices on the street and unfortunately, was getting a little more psychotic to the point that he wasn't able to care for himself. There were some behaviors that ended up causing him self-harm, not intentionally, but he just had paranoia. He had been referred to all kinds of clinics and behavioral health organizations, and was never organized enough to make it to any one of those. It took six months of us going out, interacting with him, eventually getting him on some oral antipsychotic medications, eventually providing him injectable antipsychotic medications on the street. And he's now engaging in all of his care. He's showing up to clinic visits. He is on a housing list. And that's what I mean by resource intensive, but powerful in a way that can really transform people's lives. And those are the stories that I think are not being heard. Whenever we see these news reports in these executive orders that talk about criminalizing or penalizing homelessness, because these are humans that just need a little TLC. And I think that as clinicians, we can both provide that and then help amplify and share those stories.

Anna Person: [00:21:54] Thank you sincerely to both of our guests for this conversation. It's so inspiring to learn more about the ways that we can provide really creative, compassionate care through street medicine and Medicaid. And I really just thank you for the work that you do in the ways that you were able to educate us today. For all of our listeners, you can find this podcast and the CHCS HIVMA street medicine report on the HIVMA website at HIVMA.org. Thank you for listening