What will it take for the hospital at home to stick?

Amid mounting evidence the Centers for Medicare & Medicaid Services’ Acute Hospital Care at Home program waiver improves outcomes and lowers care costs, stakeholders across the industry are calling for the program’s extension beyond its Dec. 31 expiration date. That said, an extension isn’t certain. The ability to scale programs remains in doubt, as does the value proposition for smaller hospitals as well as payers.

Under the CMS waiver, hospitals run their own programs. The earliest adopters were the nation’s notable integrated health systems: Mass General Brigham, New York’s Mount Sinai, Mayo Clinic, Cleveland Clinic, Atrium Health, and so on.

Such providers may represent the program’s ceiling.

“[E]xcept for extremely large hospital systems, most hospitals would not generate sufficient volume to support the program,” Health Affairs said in 2022, noting a 1,000-bed hospital would likely discharge 15 patients per week to the hospital at home program. (By design, the CMS waiver has strict eligibility criteria, with only about 5% of discharges qualifying.) Simply put, the negative financial impact of unfilled inpatient beds wouldn’t make up for additional Medicare reimbursement through the CMS waiver.

A recent npj Digital Medicine commentary highlighted additional obstacles.

• Evidence of effectiveness is largely limited to the first 30 days after discharge. This is important because it aligns with CMS criteria for readmission penalties, but it says little about patients’ long-term health.
• Advances in remote monitoring capabilities have outpaced the ability to input device data directly into the electronic health record. This keeps key information at arm’s length for hospital-based clinicians.
• Programs to date have left little room for personalized treatment plans. This makes it difficult to address social determinants of health.

Pathways through the hospital at home uncertainty

Payers seem skeptical of supporting the hospital at home concept. Among Medicare beneficiaries with similar care needs, the Journal of the American Medical Association noted earlier this year that traditional Medicare tends to cover more home-based services than Medicare Advantage does. Shorter “length of stay” in hospital at home, coupled with fewer visits from in-home clinicians, the paper said, “are likely associated with cost-containment strategies used by MA plans.” This resulted in lower rates of improvement in self-care, JAMA concluded.

Amid the challenges and skepticism, paths for advancing the hospital at home movement do exist. One option is to eliminate prior authorization to initiate services typically covered by insurance. This is a step Massachusetts-based insurer Point32Health recently said it’s willing to take. The plan will now approve the first 30 days of skilled services in the home – from physical therapy to social work to nutritional counseling – after a member’s initial evaluation. (Authorization will be needed to continue coverage.)

Another step is to encourage Medicaid coverage. To date, only a handful of state Medicaid agencies pay for hospital at home, and utilization is quite low. In Massachusetts — the first state to approve coverage, in February 2021 — hospital at home admissions represent less than 1% of all hospital admissions among MassHealth (Medicaid) members. One key to expansion, Chuck Pu, M.D., with MassHealth said in a webinar last year, is transparent data about where admissions happen and how they impact outcomes.

A third option, as Health Affairs and npj Digital Medicine suggested, may be taking the “hospital” out of hospital at home. Closer alignment with home health agencies, which already have the infrastructure to admit, treat, and discharge patients from home care, could make programs more economically viable for smaller hospitals – and align incentives for value-based care.