New Legislation Would Extend Hospital-at-Home Towards Permanent Availability

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Bipartisan legislation presented to Congress – if passed – would ensure that hospital-at-home care remains an option for patients of the more than 225 hospitals that have received a CMS waiver to pay for this model of care. Its passage is also expected to lead to new hospital-at-home programs from health systems that until now have been watching developments from the sidelines.

Called the Hospital Inpatient Services Modernization Act, the bill lays out a path to transition from the current state of hospital-at-home treatment – offered largely under a temporary waiver tied to the Covid-19 crisis – into a treatment option available for an additional two years with the goal of making it available under a permanent reimbursement structure.

The bill was introduced simultaneously in both the Senate and the House of Representatives last month by Senators Tom Carper (D-Del) and Tim Scott (R-S.C.), members of the Senate Finance Committee, and by Congressmen Earl Blumenauer (D-Ore.) and Brad Wenstrup (R-Ohio).

Many of the country’s leading-edge health systems have put hospital-at-home programs in place and many more have investigated initiating such a program. As the pandemic wanes and large swathes of the United States return to business as normal, those early adopters don’t want to bid farewell to their ability to offer patients access to a care model that can deliver superior clinical outcomes and higher patient satisfaction.

“As the country transitions out of the public health crisis of the past two years, the unavailability of hospital-at-home treatment is one part of the old normal that nobody wants to see return,” says Dr. Linda DeCherrie, Medically Home’s vice president of clinical strategy and implementation.

These programs offer hospital-level services at home to patients who would otherwise require inpatient treatment for serious illnesses including exacerbation of chronic diseases (such as heart failure and COPD), infections and post-surgical hospitalizations. Under Medically Home’s model, a health system’s physicians and nurses in a medical command center monitor patients in their homes 24/7. Patients receive hospital-level medical services (e.g., IV therapies, oxygen treatments, and lab tests) without having to leave their homes, and without the disruption and stress that can be experienced by hospital inpatients.

Payment for this model of care delivery has been available primarily under a program introduced by the Centers for Medicare & Medicaid Services (CMS) in November 2020. The Acute Hospital Care at Home (AHCAH) program sought to address some of the capacity strains on hospitals created by a surge in Covid-19 admissions, authorizing providers to treat Medicare and Medicaid patients in their homes for conditions that otherwise would have required inpatient care. Crucially, the program ensured that hospital networks would be reimbursed for providing hospital-at-home care at the same rate as a brick-and-mortar facility.

The CMS waiver will remain in effect for only as long as the Public Health Emergency declared by the Department of Health and Human Services early in 2020 continues. Until now, HHS has been renewing the public health emergency 90 days at a time, with the current extension set to expire July 15.

“As the country transitions out of the public health crisis of the past two years, the unavailability of hospital-at-home treatment is one part of the old normal that nobody wants to see return,” says Dr. Linda DeCherrie, Medically Home’s vice president of clinical strategy and implementation.

The legislation proposes to extend the CMS waiver for hospital-at-home care for a period of two years after the federal government declares an end to the public health emergency. It goes further, however, by setting in place a mechanism to create a long-term regulatory framework supporting the service. The bill would require CMS to issue regulations establishing health and safety requirements for hospital-at-home programs within a year. It would also require HHS to submit a report to Congress on the efficacy of the waiver program, together with legislative recommendations.

“Studies of hospital at home programs regularly show significant reductions in 30-day readmissions, post-discharge emergency department visits and skilled nursing facility utilization,” says a letter of support for the legislation signed by more than 120 health care organizations. “Patients also gain more mobility and improved sleep, and patient satisfaction is also consistently higher for patients receiving acute care in their homes.”

Widespread Support Across Health Care Sector

Given its bipartisan backing and support from a wide cross-section of the health care sector, observers believe the legislation has a good chance of being folded into one of the larger bills that regularly move through Congress and are passed into law.

“We’re at an inflection point,” says Shira Hollander, who joined Medically Home as Director of Federal and State Strategy from the American Hospital Association. Before the pandemic, there were many in the industry who saw the value of providing acute care at home, but it wasn’t prioritized widely. That’s changed because of the pandemic.

The bill’s endorsement by the American Hospital Association is especially significant. The AHA told the legislation’s co-sponsors in a March 10 letter of support that hospital-at-home programs “have been and continue to be reliable and impactful vehicles to deliver effective care.” The organization noted that some patients have shorter recovery times when they receive care in their own homes, and that home-based acute care also produces higher patient satisfaction.

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“We would welcome the opportunity to work with you and CMS to establish and implement a permanent version of the program that enables qualified patients to receive safe and effective hospital-level care in the comfort and safety of their home,” the AHA concluded.

In addition to support from the AHA, the legislation is supported by the Association of American Medical Colleges, the American Medical Association and 119 other organizations. Supporters include pioneers and key players in the hospital-at-home movement, including leading health systems (such as Kaiser Permanente, Mayo Clinic, Mount Sinai Health System and Presbyterian Healthcare Services) and enabling models like Medically Home, as well as Cardinal Health and other medical logistics entities.

Stages in Hospital-at-Home Evolution

Until the Covid-19 pandemic struck worldwide, a handful of healthcare systems had been slowly and cautiously rolling out hospital-at-home programs. First movers in this space include Johns Hopkins (which has been developing the care model since the 1990s), Mount Sinai Health System, Presbyterian Healthcare Services, a handful of Veterans Affairs Medical Centers, and Boston-area health system partners of Medically Home, which was established in 2016 to provide the technology, clinical processes and supply chain management needed to offer hospital-at-home programs.

In 2019, when Dr. DeCherrie launched the Hospital at Home Users Group along with three other hospital-at-home leaders nationwide, “there were probably about eight or 10 places across the country doing it,” she recalls. Dr. DeCherrie, who helped start Mount Sinai’s hospital-at-home program in 2014, joined Medically Home in December.

Hospital-at-home care has been studied for decades, with much of the research behind the model focused on elder care as clinicians, providers and payers have wrestled with finding ways to provide better care for older patients with serious, complex conditions that often require frequent hospitalization. Research suggests that between 20 to 30% of patients who would typically be treated in a hospital can safely receive hospital-level care in their homes.

Enter Covid-19: as the waves of infection hit the United States in 2020, filling empty beds and straining capacity in hospitals around the country, interest in this model of care delivery accelerated. Health systems and hospitals were forced to leave patients lying on gurneys in emergency rooms and hallways until beds opened up, while those in need of hospital care for Covid-19 and other ailments avoided seeking treatment, fearing that they would contract the virus or knowing that new hospital policies would bar family members from visiting them.

Under the CMS initiative introduced in November 2020, the number of hospitals and networks offering hospital-at-home as an option surged. From fewer than a dozen in 2019, as of late May 2022 there were 101 health systems and 231 hospitals in 36 states approved to transform patients’ homes into de facto hospitals under the Acute Hospital Care at Home program.

While the number of hospitals offering the service is still a small proportion of the more than 5,000 hospitals in the United States, this group includes many of the most influential health systems in the country. Dr. DeCherrie says members of this group typically are early adopters and tend to create models that others emulate or adapt.

The ultimate aim of legislators and the industry, Dr. DeCherrie says, should be to make hospital-at-home services “uniformly available to any patient who walks into any hospital.”

Passage of the bill may be the tipping point for the large number of hospitals who prefer to learn from the experience of those early adopters rather than to be pioneers in launching their own programs.

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Source: https://qualitynet.cms.gov/acute-hospital-care-at-home/resources

Passage of the bill may be the tipping point for the large number of hospitals who prefer to learn from the experience of those early adopters rather than to be pioneers in launching their own programs.

While the conversion of AHCAH from a waiver based program into a more permanent concept – as envisaged in the proposed Congressional legislation – is a critical step, CMS-funded care is only part of the hospital-at-home landscape.

That’s because the waiver applies only to the 36% of Americans covered by either Medicare or Medicaid plans. Most of the population (54%) gets health insurance coverage through their employers, and each of those commercial payers needs to negotiate with health systems over their terms for covering hospital-at-home service. (Hospital-at-home service is also covered by some accountable care organizations – health systems that receive a fixed periodic payment to cover all the costs of keeping their patients healthy, such as Medicare Advantage plans.)

Still, what happens to hospital-at-home programs authorized and paid for by CMS will have a big impact on the extent to which commercial insurers jump on the bandwagon. Historically, commercial insurers keep a keen eye on what CMS is doing and tend to follow its lead. This means that passage of the new legislation likely will drive the model of care throughout the U.S. healthcare sector.

“We expect that hospital-at-home will increasingly become the default option for patients who are eligible,” says Rami Karjian, Medically Home CEO and Co-Founder.

Hospital-at-Home Legislation Wins Broad Health Sector Support

Letter from 120
Health Care Organizations
Letter of Support Advanced Care at
Home Coalition
Letter of Support Alliance of Community
Health Plans
Letter of Support American Academy of
Home Care Medicine
Letter of Support American Hospital Association
Letter of Support Association of American
Medical Colleges
Letter of Support Moving Health Home
Letter of Support

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