The Crimson Press Curriculum Center

First Page and the Assignment Questions:
After one year as Executive Director of the Boston Health Care for the Homeless Program (BHCHP), the nation's largest provider of health care services for the homeless, Bruce Solomon outlined five essential questions facing his organization in the rapidly changing era of managed care:

   Can BHCHP’s primary care based system be successfully adapted for managed care?

   Will managed care actually save money with the special cohort of patients receiving BHCHP coordinated care without compromising quality ?

   Can actuarial risk adjustment factors for lifestyle and health status be identified and utilized in developing capitation rates that are realistic for this population?

   Can capitation be designed to work with such a relatively small patient cohort with a concentration of high insurance risk?

   Will the changes occurring in the State Medicaid and Free Care Financing systems support the delivery of health care services to vulnerable special niche populations?

After more than a dozen years experience as a hospital administrator in San Francisco, Los Angeles and Boston, Bruce had achieved a long-term ambition of working to meet the needs of homeless individuals. He had been an active volunteer and board member of homeless organizations in the three cities, where he had hospital experience. Health care colleagues cited his particular strengths in operations, finance, and human resource management. Though seemingly shy and reserved, friends attributed his past achievements to diligence, scholarship, and a management style of pragmatic realism, flexibility, and good humor that brought out the best in people.

BHCHP was in a period of rapidly changing circumstances and societal values. It had recently been awarded two multi-year grants from private foundations for research and planning for the development of a managed care-based system for homeless people. William Weld, governor of the Commonwealth of Massachusetts, had just signed a State Legislature initiated "Respite" Bill (Exhibit 1) that would encourage the licensing and use of special lower cost inpatient facilities for the recuperative care of homeless adults. BHCHP had recently added 24 new beds to it’s fully occupied 51-bed respite facility, the Barbara McInnis House, located in Boston's Jamaica Plain.

On July 1, 1996, the merger of the 13-year old publicly funded and managed Boston City Hospital (356 beds), where BHCHP patients accounted for approximately 20% of the inpatient census and 7% of ambulatory care visits, and the not-for profit Boston University Medical Center (277 beds) was approved. The merger meant that BHCHP’s ten years of operation under the umbrella of the City of Boston’s Trustees of Health and Hospitals would come to an end, and that BHCHP would become an autonomous, not-for-profit, charitable organization under Massachusetts law. On the national level, the 94th Congress had passed, and President Clinton had signed, welfare legislation that would limit federally based entitlement programs, while shifting funds to more block grants for state-by-state allotment to their needy individuals. Massachusetts was actively moving to incorporate its Medicaid recipients into managed care programs.