Omnibus Spending and Home Hospitalization Bill: A Roadmap for Ensuring Lasting Change

Buried in the thousand-page omnibus package that was recently passed by Congress was a provision that could represent the future of hospital care in the United States. The Acute Hospital Care at Home (AHCaH) initiative was one of several programs launched by Medicare as part of the regulatory flexibilities of the COVID-19 public health emergency. AHCaH allowed hospitals to receive waivers and Medicare to reimburse “hospital at home” (HaH), a care delivery paradigm in which inpatient level care is delivered to patients in their homes.

Although HaH has been tested around the world, including sites in the United States, for over 40 years, the model never reached scale in the United States, mainly because it was not not refundable by commercial and federal payers. The pandemic waiver removed that hurdle, providing the long-awaited fuel for the movement of acute care homes. As of December 16, 2022, 259 hospitals from 114 health systems in 37 states are participating. Meanwhile, new entrants have raised hundreds of millions of private capital to support HaH start-ups.

Yet while HaH has the potential to reduce costs while providing recipients with equivalent or even better quality care and outcomes, questions remain. Between 2021 and 2022, the National Academy of Medicine convened a series of expert panels that highlighted opportunities for HaH to transform inpatient care while recognizing key concerns. This included questions about equity (e.g. accessibility to rural and safety net populations), where the model could be reimbursed using alternative payment models (as the Medicare waiver used a fee-for-service mechanism) and new legal and regulatory risks to payers and providers (e.g. new sources of liability).

Because the AHCaH was linked to the public health emergency, the program will officially end once the emergency is deemed to be legally over. As a result, participating health systems and potential new entrants have been left uncertain whether these new delivery models will have a viable future beyond the pandemic. In Section 4140 of the omnibus legislation, Congress gives Medicare the statutory mandate to extend AHCaH through December 31, 2024 and allow programs to continue waiving regulatory requirements such as providing 24-hour nursing services. 24 and permission to use patients’ homes. as an eligible “origin” site for telehealth services.

However, Congress also recognizes that more data is needed before HaH can be codified into law. The Centers for Medicare and Medicaid Services (CMS) collected certain data as part of the initial waiver, including patient volume (number of discharges attributed to a hospital’s HaH program), escalation rate (number of patients admitted at “home” but later requiring transfer to a hospital facility) and unplanned mortality (deaths among HaH participants who were neither in hospice nor expected to die during admission) . Yet these measures were intentionally straightforward and simple to enable hospitals to rapidly implement HaH programs to meet the need for additional hospitalization capacity demanded by outbreaks of COVID-19 infections. These data are insufficient to allow direct comparisons with traditional hospital care in terms of quality, safety and cost. Additionally, the use of HaH during COVID-19 might have been too limited to allow meaningful interpretation, a point acknowledged by CMS in a preliminary evaluation of the model. To that end, Congress directs the Secretary of Health and Human Services to release a study by September 30, 2024, that evaluates the most appropriate eligibility criteria for AHCaH, how the quality and cost of care compares to traditional hospital care, and what, if any, there might be variations in program performance based on patient demographics (eg, race, ethnicity).

We commend Congress for preserving the regulatory flexibilities for AHCaH, which are necessary to support delivery innovation in this space, while recognizing the need for more data to inform future decision-making. As CMS plans for the next two years of the program, we recommend that regulators take the following actions.

First, while Congress calls for a study, it leaves questions regarding the design and implementation of the AHCaH assessment to the discretion of CMS. Unlike a CMS Innovation Center demonstration, the AHCaH was operated as a relatively decentralized initiative where participation is voluntary. Therefore, any data generated is likely to be observational and subject to potential selection bias. The CMS needs to think about how it collects data and needs to do so in a way that allows public access to information and independent assessment by researchers and experts. For example, CMS could consider creating a national registry to which all patients cared for under a HaH model would be automatically assigned, allowing for easy assessments and comparisons for quality, safety and outcomes of care. Similarly, costing will require the selection of appropriate control groups to account for geographic variation in spending and potential interactions with other alternative payment models (eg, global hospital budgets).

Second, although AHCaH is fundamentally a Medicare fee-for-service program, a key driver of HaH’s growth before and beyond the pandemic is Medicare Advantage, which is expected to account for the majority of beneficiaries. . in 2023. Additionally, some state Medicaid programs have also implemented HaH programs modeled after AHCaH during the pandemic. If HaH becomes a sustainable part of the health system, then multi-payer alignment will be essential. The CMS should bring together stakeholders from all types of payers to ensure consistency in the implementation of the model; exploring opportunities for performance appraisal; and providing advice to suppliers, payers and vendors on liability risk management.

Third, Congress explicitly cites a number of standard measures of hospital quality in its commissioned AHCaH study. However, two areas unique to HaH models are missing: impact on caregiver burden and provider burnout. While receiving hospital care at home can certainly be more convenient, it’s also possible that this home-based model may inadvertently exacerbate the burden on caregivers, from shifting tasks (eg, measuring vital signs) to additional costs ( for example, for Wi-Fi, for meals) to the general stress of hospitalization at home. To their credit, many HaH providers are taking steps to address this issue, such as developing caregiver training programs and providing comprehensive services, and the few studies to date measuring caregiver stress have found equivocal or improved under HaH. Similarly, HaH may exacerbate provider burnout due to the potential for increased electronic medical record data flows and interactions with third-party entities without sufficient consideration of supporting clinical workflows. Therefore, for HaH to scale, caregiver interventions and provider workflows must be standardized and evidence-based, and its impact on the needs of both stakeholder communities must be formally assessed as part of the process. CMS study.

Finally, even as CMS seeks to evaluate the existing program, regulators must also proactively consider the implications of scaling up HaH across the healthcare system. For example, although HaH is currently reimbursed at diagnosis-related group parity with traditional health insurance, a key value proposition for the model is its ability to reduce hospital expenditures. Policymakers therefore need to think about what appropriate pricing looks like and how HaH could be incorporated into ongoing value-based payments reforms. Additionally, as HaH becomes a more common route, regulators will need to ensure that there are safeguards against inappropriate use, both for low-acuity patients (who do not need hospital care) and high acuity (which require institutional care). care).

Although HaH was implemented in response to the demands of COVID-19, it has the potential to become a feature of daily care delivery in the United States. The congress gave CMS a track to create change; regulators now have two years to show whether HaH will be temporary or transformative.

Omnibus Spending and Home Hospitalization Bill: A Roadmap for Ensuring Lasting Change

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