PoS

If you think that this is a political rant, you are only partly right, but if you think that, it is probably because you have followed my posts long enough that you know what sets me off. PoS, in this instance, refers to Place of Service. More on that later.

In the world of Public Health, folks are always looking to the (time) horizon for what we call Emerging Diseases. For that matter, we even think about emerging threats to health. Among the former, I saw HIV/AIDS, Toxic Shock Syndrome, and other emerging diseases when I was an Internal Medicine resident. They seemed to come out of nowhere; they were novel diseases. Obesity, especially childhood obesity and Type 2 Diabetes became emerging health threats later in my career. More recently, SARS, MERS, Zika, and COVID have taken center stage as emerging diseases.

There are things that are not diseases as such, but that are threats to human health, nonetheless. Multi-drug resistant bacteria (so-called SuperBugs) for one. Another is the changing distribution of diseases caused by climate change – Dengue, Zika, Chikungunya, Yellow Fever and others. Then there are behavioral threats such as substance use disorders, vaping, and homelessness.

Yes, homelessness is an emerging threat to public health. When I was a resident physician back in 1979-1982, I saw surprisingly few folks who had fallen ill due, even in part, to being unhoused. There were the ant men who had fallen into an alcoholic stupor in some green space using a fire ant mound as a pillow. They came to the ER with extensive skin injuries. There were occasional poikilotherms who were found in a hypothermic coma due to exposure often potentiated by substance use and/or prescription medications. All in all, disease and injury related to homelessness was quite uncommon. Why? Because shelter was affordable, and few were homeless – mostly people experiencing untreated, severe mental illness and/or advanced substance use disorders.

But homelessness is now a significant and worsening threat to health. Many of the homeless are neither substance abusers nor mentally ill. They are simply working poor who have experienced one too many financial misfortunes that caused them to lose their lodging. Some live in their cars. Others live under the shelter of bridges. Still others live in tents in green spaces. And those in the worst circumstances sleep in doorways and on sidewalks.

When we visited our son and his lovely family a couple of years ago, he and I were driving to his local Subaru dealership to retrieve his car. He made a cell phone call as we drove there and had a conversation with a fellow that he had treated at the University Hospital for Typhus. Our son, an Infectious Disease doc, had received new laboratory results, and he wanted to change the patient’s antibiotic prescription to something that would lead to a faster resolution of the patient’s infection. After the call, I mentioned that I had never treated a patient for Typhus although I had treated patients for other Rickettsial and Spirochetal infections. He answered that it wasn’t very common except among the homeless which was a condition that his patient had.

As I have already mentioned, in Austin in 1979, homelessness was quite uncommon. Today, there are folks living in Hoovervilles throughout Austin. The city fathers passed an ordinance recently to get them out of sight – as if that actually addressed the underlying problem of an unaffordable housing market. Homelessness is an ideal setting for lice infestations (think Typhus), zoonotic illness (think mosquito-borne illness), and a host of other threats to a person’s health and well-being (think assault and rape.)

And this brings us to PoS. I read an item today that announced that the Centers for Medicare and Medicaid Services (CMS) has just added another PoS code. The new code allows physicians who care for the unhoused to bill CMS for their services using a Place of Service code that corresponds to The Street.

I think that this is social progress albeit at the margins. People who are living on the street need healthcare just as much, if not more, than people who live in a residence – no matter how humble. Still, the underlying issue has not been addressed. Perhaps a guaranteed minimal income would be a better solution.

Do we really need Bezos-Musk-Walton-etc. multi-billionaires? Are they providing an essential service to society that they could not provide if they had merely hundreds of millions of dollars? I think not.