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‘Hospital at home’ gains bipartisan support but questions remain

Hospitals seek an extension of pandemic-era program that allows some hospital patients to receive care at home

A pandemic-era program that pays hospitals to provide acute inpatient care in patients’ homes will expire at the end of this year unless Congress acts.
A pandemic-era program that pays hospitals to provide acute inpatient care in patients’ homes will expire at the end of this year unless Congress acts. (Bill Clark/CQ Roll Call file photo)

Congress is looking to extend a Medicare program that pays hospitals to provide acute inpatient care in patients’ homes, even as questions remain about how that program impacts health outcomes and health care costs.

Hospitals are seeking at least a five-year extension of the Acute Hospital Care at Home program, which was launched during the pandemic to help overstretched hospitals deal with capacity issues. The program expires Dec. 31 unless Congress acts. Hospitals have continued the program after the pandemic for patients who need hospital-level care but can be monitored from home, freeing up beds for other patients.

Both the House Ways and Means Committee and the Energy and Commerce Health Subcommittee have advanced bills that would extend the program for five years, with both panels citing the need to ensure Medicare beneficiaries continue to have access to it. A five-year extension will allow for more time to gather data while allowing hospitals to get their programs off of the ground, hospital groups say.

“One of the common themes we have heard from our members is that long-term stability is needed within the H@H [hospital-at-home] program,” Lisa Kidder Hrobsky, senior vice president of advocacy and political affairs for the American Hospital Association, wrote in an April letter to Reps. Brad Wenstrup, R-Ohio, and Earl Blumenauer, D-Ore., who have introduced a third bill that would extend the program. 

The AHA hopes that will lead to 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.”

But outside experts caution that more data is needed.

The Medicare Payment Advisory Commission, which advises Congress on Medicare policy, said in its June report that the current structure of the program and the data that is collected makes it difficult to compare health outcomes and costs for patients who are treated at home versus in the hospital. 

“Whether AHCAH can provide value to beneficiaries and the Medicare program — through better outcomes and reduced Medicare expenditures for follow-on care — has yet to be conclusively determined,” the report states.

The Centers for Medicare and Medicaid Services launched the Acute Hospital Care at Home program — known as “hospital at home” — during the pandemic as hospitals faced shortages of beds.

Participating hospitals must meet certain requirements, including the ability to provide two in-person visits by clinicians each day, in addition to a daily physician visit that may be virtual. Hospitals must also have a round-the-clock system for patients to reach out to clinicians with concerns, and be able to provide emergency services within 30 minutes.

The program was set to expire at the end of the public health emergency but was extended by Congress through the end of 2024. Now hospital groups and hospital-at-home providers and investors are lobbying for a five-year extension, claiming it is appreciated by patients, can save money and lead to improved health outcomes.

“Congress has signaled that they are very interested in this,” said Krista Drobac, a partner at Sirona Strategies and founder of Moving Health Home, a coalition of stakeholders advocating for the hospital-at-home waiver. “I think it’s pretty safe to say we’re going to have something in the future.”

Congressional action

In May, the Ways and Means Committee advanced a bill that would extend the program for five years, while the Energy and Commerce Health Subcommittee advanced a similar bill that would also extend the program for five years.

The program has sparked a lobbying rush, with 23 health systems, hospital organizations and coalitions listing it on their first-quarter lobbying disclosures in 2024, compared to 16 organizations that lobbied on the issue in the first quarter of 2023.  

That includes Amedisys, a home health company that in 2021 acquired Contessa Health, a hospital-at-home business.

Hospital at home has become a promising moneymaker for certain hospitals and potentially private equity investors, said Eileen Appelbaum, co-director of the Center for Economic and Policy Research, where she has studied hospital consolidation and private equity.

Medicare pays the same amount for hospital-at-home cases as it pays for an inpatient hospital stay.

They also are still allowed to charge facility fees, which are sometimes billed by hospitals to help cover the cost of overhead and equipment.

“I do think that careful selection of patients and the conditions that are being treated has enabled hospital at home to be valuable, but taxpayers are greatly overpaying for it,” Appelbaum said. “It’s money for nothing on the facility fee because there are no facilities involved.”

Sources of concern

MedPAC has pointed to the reimbursement rate as a potential issue that should be studied more.

“The equal rate may not be appropriate if AHCAH [hospital-at-home] discharges do not have the same costs as brick-and-mortar acute care stays,” MedPAC wrote in its June report.

There is also currently no mechanism for Medicare to “share in savings” if hospital-at-home care is “less costly than usual care.”

MedPAC said the current structure of the program makes it difficult to measure patient outcomes, especially when compared to people who receive care in the hospital.

While hospitals must provide reporting on three metrics to CMS, including on unanticipated mortality, the number of cases sent to hospitals and the total number of discharges, that does not “provide a direct measure of care that beneficiaries receive in the home.”

It would be more useful to know whether hospital-at-home patients are experiencing fewer falls or infections compared to patients in hospitals and if patients are able to contact their care team after hours, the report said.

More data should also be collected on the use and outcomes of remote patient monitoring, which typically records patient vital signs and other health information, MedPAC said.

Still, MedPAC said, low mortality and escalation rates suggest “inpatient hospital-level care can be provided safely in the home for some patients.”

More to come

If the program is extended, the coming years will prove a test.

CMS is expected to publish a study later this year comparing how quality and cost of care compare to traditional inpatient care and what, if any, variation there is between program performance based on patient demographics.

Both of the bills that advanced at Ways and Means and the Energy and Commerce Health Subcommittee would require CMS issue a report in 2028 about the quality of care, outcomes, costs and the quantity and intensity of services between people who enter the hospital-at-home program directly from an emergency department compared to people who enter through an existing inpatient stay in a hospital.

Extending the program another five years could encourage more participation by hospitals.

As of April 2024, CMS reported that more than 23,000 hospital-at-home discharges have occurred, and 328 hospitals have been approved to participate, according to MedPAC. 

But not all hospitals that have been approved actually participate.

In 2022, active hospitals — defined as having one or more discharges that year — had an average of 59 discharges that year. The 26 hospitals with the highest volumes accounted for 71 percent of all program discharges.

“The limited volume and participation to date likely reflect the complexities of creating such a program,” MedPAC stated.

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