Monica Bharel, MD, most recently served as Medical Director at Boston Health Care for the Homeless Program in Boston, MA. She is an instructor of medicine at Harvard Medical School/Massachusetts General Hospital and an assistant clinical professor of medicine at Boston University School of Medicine/Boston Medical Center. Her areas of interest include preventive health care and chronic disease management for underserved populations through system-based improvements. Her areas of research have included cervical cancer screening in homeless women, treatment of alcohol use among homeless women, hepatitis C in vulnerable populations and medical resident education. Dr. Bharel received her medical degree from the Boston University School of Medicine in 1994 and in 1998, completed a residency and chief residency in internal medicine at Boston Medical Center.
Monica Bharel, MD, MPH
Massachusetts Commissioner of Public Health; Instructor in Medicine, Harvard Medical School/Massachusetts General Hospital; Assistant Clinical Professor of Medicine, Boston University/Boston Medical Center, Boston, MA
As a physician at Boston Health Care for the Homeless Program since 2003, Dr. Monica Bharel knows the work she and her staff do to build trust with the more than 12,000 patients the program sees annually at nearly 80 shelters and other sites around the city is just as important as the medical care she delivers.
Health Care Utilization and Cost among Homeless Medicaid Recipients
The goal of this project was to understand utilization and expenditure patterns for homeless individuals in order to include this marginalized segment of our population in health care reform efforts.
Homeless individuals are vulnerable members of our society who live in challenging circumstances and suffer from high rates of medical and behavioral health illnesses. Homeless individuals die younger and have a shorter life expectancy than other poor individuals. They are also high users of the medical system, including the emergency department and acute hospital systems. As we reform our health care delivery and payment system, we will need to better understand their unique medical characteristics and health care utilization patterns.
Three organizations were involved in analysis of two datasets. Boston Health Care for the Homeless Program (BHCHP) has spent the last two decades providing health care and access to homeless individuals in Boston. MassHealth, Massachusetts’ Medicaid program, is an important partner of BHCHP, as almost 80% of BHCHP patients have MassHealth coverage. The third partner is the University of Massachusetts Medical School that manages the MassHealth claims database. BHCHP patients seen in 2010 with MassHealth coverage constituted the first database. This information was merged with MassHealth claims data.
Claims data was evaluated on 6,494 patients. Consistent with clinical suspicion and past studies, the data show high burdens of disease. 68% of patients had mental illness, 60% with a substance use disorder and 64% with a specified chronic medical illness. Additionally, data show high hospital and ED usage with 21% of patients having 5 or more visits to the ED in a year with associated high expenditures.
Homeless individuals have an extraordinarily high burden of medical and mental health disease and have a high level of health care utilization. Future studies are needed comparing this population to other Medicaid populations. Innovative program design for homeless high users will also provide valuable ability to evaluate improvements in health care quality and utilization as we reform our health care system.
Preceptor and Sponsoring Agency:
- Bob Taube, Boston Health Care for the Homeless Program
- Wen-Chieh Lin, UMass Medical School Center for Health Policy and Research
- Lori Cavanaugh, MassHealth