Providers push for continued hospital-at-home waiver after pandemic

Hospital systems are making the case to Congress that Medicare should continue covering hospital-at-home care after the public health emergency, arguing it could improve health outcomes, lower costs and alleviate capacity and staffing issues.

More than 200 hospitals have received a waiver from the Centers for Medicare and Medicaid Services to participate in the program, but Medicare’s hospital-at-home coverage expires at the end of the public health emergency, which could come as soon as July. Some federal lawmakers are working to extend the waiver for at least two more years, but they’re unlikely to pass legislation before coverage lapses.

Meanwhile, some health systems are trying out risk-based home hospital payment models with private payers. Some say they are seeking a more permanent solution via the Center for Medicare and Medicaid Innovation that could allow them to better tailor the program to their patient mix and organization.

“We are very optimistic that we will be able to gain support for the extension of the waiver because at this point it doesn’t make sense to lose the progress we’ve made over the last two years,” said Piper Nieters Su, division chair of external relations at Mayo Clinic. “But there are no givens in Congress these days—the value proposition is a legitimate question members of Congress have.”

A bill introduced last week by Sens. Tom Carper (D-Del.), Tim Scott (R-S.C.) and Reps. Earl Blumenauer (D-Ore.) and Brad Wenstrup (R-Ohio) would extend the hospital-at-home waiver for two years after the end of the public health emergency.

The senators hop to collect more data that could justify a permanent expansion with their proposal. But the bill faces limited legislative pathways before the end of the year, when Congress will likely pass a government funding bill that typically includes dozens of health policy provisions.

“At this point, it’s probably most likely going to happen in December, which would mean that there could be a gap in services for patients in their homes,” said Krista Drobac, a partner at Sirona Strategies, which launched Moving Health Home, a coalition of providers involved in home-care. “We are trying to send the message to our members that there will have to be a pause in the program and potentially a long-term dismantling of the program if we can’t get the authorities extended.”

CMS launched Hospital at Home Waiver in late 2020, allowing approved hospitals to treat patients with acute conditions such as pneumonia and congestive heart failure in their homes. More than 90 health systems in 34 states have received waivers, including Mount Sinai in New York, Marshfield Medical Center in Wisconsin and ProMedica, which is based in Ohio.

Participating hospitals don’t have to provide nursing services on premises 24 hours a day, 7 days a week in order to receive reimbursement. The waiver allows patients to be monitored remotely, and for physicians, nurses and other caregivers to visit the patient’s home once or more per day. Studies have shown similar programs can improve health outcomes and reduce healthcare costs.

The COVID-19 pandemic accelerated Medicare and private payers’ home hospital care and telehealth reimbursement plans. Congress’ $1.5 trillion government funding bill passed last week included expanding Medicare telehealth coverage, as lawmakers are willing to embrace virtual care.

But the legislation didn’t include an extension of the waiver, despite efforts by Rep. Brad Wenstrup (R-Ohio), a physician by trade, and other lawmakers.

Part of the reticence to extend the waiver is a lack of cost data and small sample sizes associated with quality metrics. Home hospital care has been around for years, but it was not covered by traditional Medicare until the pandemic. Lawmakers want CMS to share more data on cost, utilization and health outcomes before they extend the waiver.

About 1,900 patients had been admitted to hospital-at-home programs as of Oct. 27, according to a New England Journal of Medicine study published in December. About 66% were Medicare fee-for-service beneficiaries. There were eight unexpected mortalities, or 0.4%. The average inpatient mortality rate is between 2% and 3%.

But that doesn’t give researchers enough data to analyze the program, authors said. Extending the program for another two years would provide more data, supporters of the legislation say.

There also isn’t a lot of information about how much the waiver has cost Medicare.

“There is a lack of real understanding of how the program works on Capitol Hill,” said Paul Lee, senior partner and founder of Strategic Health Care, which works with hospitals participating in the program. “We really have no cost information.”

It would be difficult for Congress to pass a proposal that costs Medicare a significant amount of money without cost savings or quality improvements. Under the waiver, Medicare pays the same for in-home hospital care as it does for care in a facility.

“We feel the best reimbursement structure is in a value-based arrangement,” said Travis Messina, co-founder and CEO of Contessa, a hospital-at-home company that primarily worked with Medicare Advantage plans before the pandemic. “If you are shifting the site of care to the home, which is a lower-cost setting, Medicare should realize the benefit of that reduced cost.”

The hope is that after the two-year period, Congress would make the program permanent with a value-based payment component, Messina said.

Some hospitals have been reticent to implement their hospital-at-home waivers because of long-term uncertainty, said Lee of Strategic Health Care. Such programs can take three to four years to recoup health systems’ investments, according to studies of similar programs.

Increased stability could encourage more hospitals to take the plunge, but Lee noted that some are also worried that the two-year extension is also not enough time.

Some providers view the legislation as a stopgap and a way to keep momentum as they test out their hospital-at-home programs and try to win over CMMI on a new model.

Mayo Clinic, which invested $100 million in Medically Home to scale its hospital-at-home program with Kaiser Permanente, is working with the CMMI to develop a permanent risk-based payment model for acute home-based care through Medicare.

Hospitals are paid based on the standard inpatient length of stay for similar care and other post-acute care expenditures in current bundled payment models with private payers. The hospital would retain any savings generated from shorter lengths of stay and hitting quality measures related to hospital readmissions and skilled nursing admissions.

Currently, Mayo’s hospital-at-home patients’ 30-day mortality rate is less than 1%, Mayo executives said. Its hospital-at-home program has a 30-day readmission rate between 8% and 12%, while the national average is around 20%.

Home-based acute care is typically 20% to 40% cheaper than brick-and-mortar-based inpatient care, national studies show.

“We are exploring the possibility of a CMMI model rather than pursue legislation to create a new Medicare benefit category because there is flexibility in how providers are offering home hospital services,” Mayo’s Nieters Su said. “We want to maintain that flexibility so providers can build a program that best serves their community, but we need some guardrails and consistency to understand what the cost savings and outcomes are going to be.”

The Medicare waiver doesn’t offer that flexibility, providers said. Patients travel from around the world to Mayo, often staying at a rental or a hotel. Although the setting is safe and appropriate, patients have to be at their primary residence to meet the waiver’s requirements, Nieters Su said.

“We can do better than the existing waiver, which is fairly rudimentary in the elements it waives,” she said. “It is the only pathway to do this type of care on an inpatient basis so it is critically important, but over the longer term we want a model with greater measurement capabilities that can account for more complex patient situations.”

As some health systems opt to pause or delay their home hospital program rollout, those that have spent the time and money rolling out the infrastructure, equipment and workflow for these programs are worried that it will be wasted.

Jefferson Health, which recently launched a home hospital program in Edison, New Jersey, supported the legislation to extend the waiver beyond the public health emergency.

Outside of cost and quality comparisons, lawmakers may be interested in equity in access to home hospital programs.

Kaiser’s hospital-at-home program has been equitable in terms of its reach and it hasn’t overburdened families, said Dr. Mary Giswold, chief operating officer at Northwest Permanente.

Home hospital care has the opportunity to limit transportation, require family members to take less time off work and build partnerships with community organizations to address issues like nutrition and living conditions, said Dr. Sarita Mohanty, CEO of the SCAN Foundation.

“We must ensure hospital-at-home programs are provided to all who are eligible—we don’t want to make disparities and inequities worse,” she said Tuesday during a webinar hosted by Kaiser. “As we work to scale these models, we need to be mindful of not just the clinical, but the social and behavioral factors that influence one’s total health.”