Hospital programs providing at-home acute care are widely appreciated by patients and clinicians but still don’t have a bulletproof argument in respect to quality and costs as compared to a brick-and-mortal inpatient stay, according to a Centers for Medicare & Medicaid Services (CMS) analysis published Monday.
The agency’s 79-page report characterizes the “best-available quantitative and qualitative data” on its Acute Hospital Care at Home (AHCAH) initiative, which, during the pandemic, began issuing waivers for certain hospitals to shift care into the home.
Those waivers and flexibilities were extended through 2024 in 2023’s Consolidated Appropriations Act, which also required CMS to develop and publish Monday’s report.
As of July 24, a total of 332 hospitals across 38 states have been approved to participate in the AHCAH initiative, according to the report.
These hospitals largely determined which patients to enroll in their programs using criteria aligning with published literature on hospital at home (HaH) programs. They aimed to select patients who would be “willing and able” to participate in acute home care, both clinically and in respect to their home environment.
As such, Medicare beneficiaries enrolled in the program had “meaningfully different” characteristics than their brick-and-mortar peers, CMS found. AHCAH participants were more likely to be white and live in urban areas and were less likely to receive Medicaid or low-income subsidies. Patients in the programs were also primarily treated for “a relatively small set of conditions,” which included respiratory, circulatory, renal and infectious disease care.
Quality, cost and utilization comparisons between the AHCAH and brick-and-mortar patients painted a promising, but not quite clear-cut, case for the novel care model.
Thirty-day mortality rates, for instance, were lower for AHCAH patients. Rates for six hospital-acquired conditions were also lower among those patients, though not enough to be statistically significant.
Thirty-day readmissions for some Medicare Severity Diagnosis Related Groups, including those related to complex clinical conditions related to respiratory infections, were significantly higher for AHCAH patients than their peers. Other diagnostic groups reflecting relatively less complex respiratory and infectious conditions had significantly lower readmissions.
Though AHCAH patients’ length of stay was, on average, “slightly” longer than comparable brick-and-mortar patients, more than half of the studied diagnostic groups showed lower Medicare spending on services furnished within 30 days of discharge.
That said, “the differences attributable to AHCAH patient selection criteria and clinical complexity, as measured across the two groups, make it difficult to conclude that the AHCAH initiative resulted in lower Medicare spending overall as compared to brick-and-mortar inpatient care,” CMS wrote in the report’s executive summary and a corresponding fact sheet.
The agency acknowledged a lack of data on direct costs incurred by hospitals as a “significant limitation” of its study’s comparisons but noted that external literature reviews and other data “gleaned from various data sources analyzed in conducting this study” suggest that the programs can be cost effective for hospitals “in certain circumstances.”
CMS also speculated that these outcomes could be on an upward trajectory, as “there have been multiple lessons learned regarding the continuous quality improvement efforts for improving health and safety of inpatients in the home setting, and opportunities to further develop more targeted measures of cost, quality and utilization.”
Contrasting the less conclusive quality and cost findings was glowing feedback from those participating in the programs.
In virtual listening sessions, site visits and other forums, CMS received “overwhelmingly positive” responses from patients, family members and caregivers. The patients said they were more relaxed and less depressed in their homes, “which seemed to aid their recovery,” while the others said they appreciated tech-enabled communications with care teams and more involvement in the patient’s care.
Those sentiments were “mirrored” in the feedback from clinicians, who described care through the program “as being professionally fulfilling, renewing the joy they experience in providing clinical care,” CMS wrote in the report.
CMS said it would continue to review available data on the AHCAH initiative. It wrote that the current report’s analysis of Medicare claims and codes “was as rigorous as possible” given time and data limitations but that “significantly more time and capacity” may be necessary to clarify the questions around quality and costs.
The findings of CMS’ report could play a role in whether Congress reauthorizes the acute hospital care at home waivers, which are set to run their course at the end of the year. Such a move is backed by several industry stakeholders and the Bipartisan Policy Center, which advocated for a five-year extension in a summer report.
Key lawmakers have suggested that a two-year extension has “broad bipartisan support,” and, in September, a bill that would provide such an extension advanced out of committee in a unanimous vote.