Healthcare leaders are calling on Congress to extend a waiver that expanded flexibilities for hospital-at-home programs, saying continued reimbursement is critical to scale up these programs.
Temporary waivers rolled out by the Centers for Medicare & Medicaid Services (CMS) under the public health emergency have allowed Medicare enrollees to receive acute hospital-level care from their own homes.
During a Hospital at Home Week of Action, dozens of organizations including the American Medical Association, the Alliance of Community Health Plans, Mayo Clinic, CardinalHealth, Kaiser Permanente, Mount Sinai at Home and Providence advocated for lawmakers to extend the current waivers, providing certainty for health systems and plans to provide personalized at-home care.
“This is an example of a successful program that has been critical during the pandemic,” Rep. Earl Blumenauer, D-Oregon, one of the legislators who introduced the legislation extending the waiver. "But it’s still essential and can be a building block as part of our long-term realignment of a healthcare system that prides and rewards value over volume, is open to innovation and the needs of individual patients," Blumenauer said.
Blumenauer and health system leaders spoke about hospital-at-home programs during a webinar last week sponsored by the Advanced Care at Home Coalition and McDermott+Consulting. Other healthcare leaders also addressed providing acute care at home during the Forbes Health in Action Summit.
Still a burgeoning model
“This is a space that has chronically lacked a lot of investment,” said Bill Miller, CEO and chairman of the board of WellSky. That has changed in the last five years, he added.
Three factors today enable the model, explained Medically Home co-founder and CEO Rami Karjian: Clinicians available around the clock for patients getting care at home; technology enabling remote care and communication; and services available for safe delivery at home. “Consumers as patients prefer to be taken care of in their home. They get better outcomes in their home,” Karjian said.
Even before COVID-19, commercial payers were interested in reimbursing for this model because of its ability to lower costs while maintaining positive outcomes. As an example, Constantinos Michaelidis, M.D., medical director of hospital-at-home for UMass Memorial Health, said the health system's program has been most impactful among Medicaid and Medicare patients, with up to 75% reductions in 30-day readmissions.
Speakers emphasized at-home care enables clinicians to see patients in a more holistic way, where social determinants of health are clearly evident in a way they cannot be addressed when a patient visits a clinic. That can be more rewarding for nurses, said Mae Centeno, chief nursing officer of virtual care center and virtual care delivery at Texas Health Resources. “They don’t want to wait until they’re burnt out, but they want to have another avenue to use their skill set," she said.
The largest nurses union, National Nurses United (NNU), has been outspoken against at-home care programs, arguing they are a danger to patients and undermine the expertise of registered nurses critical to a safe recovery. The NNU has expressed concern about existing studies purportedly showing benefits of such programs as being selectively chosen and limited in scope and believes the primary driver of these programs is the desire for revenue. The programs, the union says, threaten to exacerbate racial disparities among those under-resourced and may drive inpatient services out of business altogether.
The union has urged payers to invest in the existing healthcare infrastructure and workforce.
Scaling for the future
Miller acknowledged the continued need to show data that this model, indeed, generates better outcomes at lower cost. He also called on the U.S. to recognize this as a sustainable operating model. “We need the will to do it—the technology is there," he said. This problem, he added, is why reimbursement is currently “hanging in the balance.” Though he believes the waiver extension will pass, that may take more time than going to payers directly who are usually quicker to adapt, especially if it saves them money.
At-home care offerings can make providers more competitive, too. One patient came to UNC Health “‘because the one down the street does not have this program,’” recalled Matt Smith, the health system’s vice president of digital health/virtual care and well care services.
Apart from reimbursement, another hurdle to scaling home hospital programs is the workforce shortage, speakers said. This could potentially be addressed by having clinicians manage several patients across multiple states through one command center. Programs can also tap into atypical labor pools for care, like paramedics or community nurses.