Health-minded lawmakers are in conversations with House leadership on reviving health legislation that failed to make it into a December government funding bill.
Rep. Buddy Carter (R-Ga.), chair of the Health subcommittee on Energy and Commerce, told reporters on Thursday he’s in conversations with leadership to pass the more than 500-page health package, either in a stand-alone vote or included in a reconciliation package.
“I’d like to do it as a standalone, get it done, and have it behind us, personally,” Carter said. “If we did it through suspension, we could probably put it on the floor. I mean, it was an agreement. It was bipartisan, bicameral.”
The large health care package that was eventually stripped out of the end-of-the-year government spending deal held a number of notable provisions, including language that would rein in pharmacy benefit managers for the first time, boost Medicare doctor payments, and extend telehealth services for multiple years. However, the package was ultimately stripped out and replaced with a standard three-month extension of funding after President-elect Donald Trump rejected the bipartisan deal with Democrats, and made additional demands.
Rep. Greg Murphy (R-N.C.), chair of the Doctors Caucus, confirmed there have been conversations about putting the package up for a suspension vote.
“Given the bipartisan nature of” PBM reform, “and a few other things, I think it would pass,” Murphy told Bloomberg Government in a written statement Thursday. “Obviously, it will be up to the Speaker.”
The December-passed government funding deal extended existing health authorities for three months, but stripped out principal health provisions, such as a regular “doc pay fix” provision that would’ve staved off a 2.8% Medicare payment cut for doctors that took place at the beginning of January. Murphy had previously told Bloomberg Government he secured an agreement with the Trump transition team to include a retroactive “fix” in the next government funding deal.
A spokesperson for Speaker Mike Johnson did not immediately respond to a request for comment.
House Energy and Commerce Chair Rep. Brett Guthrie (R-Ky.) had told reporters Jan. 3 the policies in the killed health package are “alive again.” Lawmakers, however, are still trying to find the right vehicle for it, with reconciliation measures being a possibility.
The collapse of the continuing resolution has seriously threatened an elaborately negotiated health care package that touches virtually every medical industry.
Why it matters: After weeks of intense bipartisan and bicameral talks, and months of laying the groundwork, the package’s major reforms, reauthorizations of existing laws and extensions of funding streams could all be scrapped.
Driving the news: The sources we talked to today do not see a clear path forward for the health care package, and no one’s sure what will happen.
What they’re saying: “Members got greedy and tried to hang too many ornaments on the tree; now it seems to have fallen over,” Raymond James analyst Chris Meekins told Axios.
Options for what happens next include a pared-down CR with some disaster relief for farmers and language raising the debt ceiling, as President-elect Trump is insisting.
Friction point: Don’t discount that Democrats will likely still need to deliver some votes on any compromise, considering the unruliness and potential defections of the House Republican conference and the 60-vote threshold in the Senate.
If another bipartisan compromise emerges, that would leave some opportunity for health items to catch a ride.
What’s next: If the health package is dropped, another chance could arise in March if there is another government funding bill. But it’s unclear if the odds would be any better, or if priorities shift.
Hospitals dodged the most substantial efforts in the year-end spending package to reform their industry, but advocates tell Peter the door has at least been cracked opened by a limited measure on outpatient billing.
Why it matters: After years of focusing on drug costs, this Congress started to train more attention on hospitals, which constitute a much larger share of U.S. health spending.
Driving the news: The CR includes a measure that would require off-campus hospital outpatient departments to have a unique identifier number, known as an NPI.
What they’re saying: The NPI provision “is a sign that a small victory can be won,” said Sophia Tripoli, senior director of health policy at Families USA.
Between the lines: Although hospitals opposed the NPI provision, site-neutral was more of an industry focus and a much bigger threat because of the way it addressed how hospital-owned providers charge Medicare more for the same services that independent doctors deliver in their offices.
Still, hospitals realize they need to remain on guard heading into next year.
The big picture: Hospitals are a powerful political force, given that they’re major employers in many members’ districts.
The other side: Hospitals argue that site-neutral payments do not account for higher costs at hospital outpatient departments and would especially harm rural areas — a particularly potent potent argument in the Senate.
What’s next: Backers of hospital cost reforms are hoping Congress will take broader action on site-neutral next year.
As 2024 comes to a close, we are looking ahead to the 119th Congress and opportunities for our clients to engage with their federal representatives and other decision makers in Washington, DC.
• View House and Senate calendars
• Questions? Contact Tony Wyatt: anthony@wscdc.com
Congressional Swearing-In Day Friday, January 3rd, 2025 | 9:30 AM – 3:00 PM U.S. Capitol, Washington, D.C.
Join us for a day of celebration as Members of the 119th Congress are sworn into office. Many lawmakers welcome visitors for informal open house style receptions throughout the day in their Capitol Hill offices. WSC will provide a schedule of events as details emerge.
Dinner Reception for Congressman Tom Kean (R-NJ-07) Tuesday, January 7th, 2025 | 5:00 PM – 8:00 PM Winning Strategies, 409 7th St NW Suite 450
Garden State Inaugural Gala Sunday, January 19th, 2025 | 7:00 PM – 11:00 PM Grand Hyatt Washington, 1000 H Street Northwest Washington
Join the New Jersey State Society at the Garden State Inaugural Gala for the best of New Jersey’s food and entertainment. Don’t miss this chance to celebrate with fellow New Jerseyans in the heart of the nation’s capital. Register here
Reception for Congressman-Elect Herb Conaway (D-NJ-3) Wednesday, January 22nd, 2025 | 6:00 PM – 8:00 PM Winning Strategies, 409 7th St NW Suite 450
Reception for Congressman-Elect Nellie Pou (D-NJ-9) Thursday, January 23rd, 2025 | 5:30 PM – 7:30 PM Winning Strategies, 409 7th St NW Suite 450
Reception for Congressman Jeff Van Drew (R-NJ-2) Wednesday, February 5th, 2025 | 11:00 AM – 2:00 PM Capitol Hill Club, 300 First St SE
The Walk to Washington & Congressional Reception February 6th – 7th, 2025 Hosted by: New Jersey Chamber of Commerce
After a five-year hiatus, the 84th Walk to Washington will feature more networking opportunities and fewer speeches, bringing together 900 New Jersey leaders on a chartered Amtrak train traveling from Newark through Wilmington, DE, to Washington, D.C. Register here
Related Walk to Washington Events:
WSW-PPAG NJ Chamber of Commerce Dinner Thursday, February 6th | 7:00 PM – 9:00 PM The Palm, 1225 19th St NW
Irish Breakfast Reception Friday, February 7th | 8:00 AM – 10:00 AM The Dubliner, 4 F St NW
Reception for Congressman Rob Menendez (D-NJ-8) Thursday, March 6th, 2025 | 12:00 PM – 1:00 PM Winning Strategies, 409 7th St NW Suite 450
We look forward to seeing you at these events! If you have any questions or need additional details, please don’t hesitate to reach out.
Key Updates:
• 2025 Congressional calendars now available
• Multiple January events including Congressional Swearing-In Day
• Walk to Washington returns in February after 5-year hiatus
• Several opportunities to meet with New Jersey delegation members
Language addressing insurer prior authorizations in Medicare Advantage that was holding up a year-end health care deal is likely to be dropped by negotiators.
Why it matters: Insurers’ requirements for their sign-off on some physician-ordered care is a big tension point with patients and providers, and measures to streamline the system have been a focus of Congress and the Biden administration.
Inside the room: One sticking point is whether to codify a prior authorization rule the Biden administration issued this year, or to include a prior authorization reform bill known as the Improving Seniors’ Timely Access to Care in the package.
Friction point: There’s a slight difference in transparency requirements for insurers, and where information on prior authorization denials and related information would be posted.
What they’re saying: Over the weekend, Democrats characterized Republicans’ efforts as “watering down” the prior authorization requirements.
Context: The bill has the bipartisan support of majorities in both the House and Senate.
Congressional Republicans made Democrats an offer on a major package of year-end health provisions this week, sources say.
Why it matters: The large-scale offer shows that momentum remains behind finishing a major health package this year, though a deal is far from certain.
What’s inside: The offer includes additional health policies beyond what are regarded as “must do” extenders like community health center funding and telehealth flexibilities.
The big picture: Despite the offer, there is a long way to go. Some sources still expected that negotiators will run out of time and have to fall back on a three-month bare-bones extension of expiring programs.
The legislation would limit prices and ban hospital facility fees for dozens of health services deemed safe to get in a doctor’s office.
State lawmakers are moving to cap prices for dozens of routine health care services, saving New Yorkers an estimated $1 billion annually.
New legislation sponsored by state Sen. Liz Krueger and Assemblymember Chantel Jackson is designed to eliminate massive price discrepancies between hospital-owned facilities and doctor’s offices for the same services.
“The affordability of health care shouldn’t depend on what building it’s delivered in,” Krueger, whose Manhattan district includes many of the city’s biggest hospitals, said in a statement. “We cannot let big hospitals become the next Big Oil or Big Steel, with monopoly control over everything and people forced to pay more for the same basic procedure.”
If passed, the “Fair Pricing Act” would prevent most types of health care facilities from charging more than 150 percent of the Medicare rate for a specified set of services, such as vaccinations, MRIs, chemotherapy infusions and IV hydration. Public, safety-net and rural hospitals and federally qualified health centers would be exempt.
The prices of those services can vary immensely, according to 2022 claims data from the health fund for building service workers union 32BJ, which worked on the legislation. A flu shot in a doctors office averaged $23, compared with over $183 in a hospital’s outpatient center, according to the data. An initial, one-hour chemotherapy infusion averaged $410 in an office setting but $2,650 in hospital-owned outpatient facilities.
“The data’s pretty damning,” Claire Brockbank, director of policy and strategy for union’s benefit funds, said in an interview.
The bill’s impact could be far-reaching: Brockbank said it was written to apply to New Yorkers on most kinds of insurance, as well as patients paying out of pocket.
More context: Such price variations have caught the attention of policymakers across the U.S., as hospitals increasingly buy up local medical practices and hike their prices, in part by tacking on a so-called “facility fee” intended to help cover overhead.
New Yorkers would have saved more than $1 billion in 2022 if select services performed in hospital settings were paid the commercial insurance rate for doctor’s offices, according to research presented at a conference on hospital prices hosted by the union’s health fund earlier this year.
Sens. Bill Cassidy (R-La.) and Maggie Hassan (D-N.H.) released a bipartisan plan earlier this month to cut Medicare payments to hospitals’ outpatient departments to the level paid to independent practices.
New York lawmakers appear to be leading the way among state legislators with the introduction of their site-neutral legislation.
The bill is likely to provoke the state’s powerful hospital industry, which lobbied heavily against a prior legislative effort to ban facility fees. By the time that bill passed in 2021, it had been watered down to apply only to preventive services and otherwise required that hospitals simply give patients advance written notice of any facility fees not covered by their insurance.
The hospital industry insists the higher rates and facility fees are justified because they are subject to more stringent safety requirements and typically care for more complex patients.
What’s next: Krueger and Jackson’s bill will be taken up when the state Legislature reconvenes in 2025.
Acquisitions in the home care industry are poised to take off in 2025, fueled by lower interest rates and President-elect Donald Trump’s incoming administration.
Large home care providers including Addus HomeCare, Aveanna Healthcare and the Pennant Group said during third quarter earnings calls they would aggressively look for deals next year to gain scale and better compete for hospital referrals. The interest in deal-making is an about-face for an industry that has been burdened by labor shortages, rising costs and battles with Medicare Advantage organizations over better rates.
“[Consolidation] is definitely about scale and volume in exchange for rates,” said Tyler Giesting, director of healthcare and life sciences at advisory firm West Monroe. “As they grow, it also improves their top line so they can invest in capabilities they need to run the business in a way that the MA plans require, such as reporting on value-based care measures.”
The appetite for acquisitions spans home healthcare, personal home care services, private duty nursing and hospice companies.
Jeff Shaner, CEO of Aveanna Healthcare, told analysts during an earnings call the company was “revving up the M&A engine” to acquire home health, private duty nursing and hospice organizations in 2025. The Atlanta-based company operates in 22 states.
The Pennant Group CEO Brent Guerisoli said the Eagle, Idaho-based company wants to expand its footprint in home health. The company offers home health and hospice services across 13 mostly western states. In August, the Pennant Group acquired assets in Oregon, Washington and Idaho from Signature Healthcare at Home for $80 million.
“We are an opportunistic company and we are going to grow where we have strength and where there is great opportunity,” Guerisoli told analysts during an earnings call.
Addus HomeCare CEO Dirk Allison also told analysts during an earnings call the Frisco, Texas-based home care company would be looking to buy home health and personal care businesses after it completes the $350 million acquisition of Gentiva’s home care business, which is expected by the end of the year.
Addus HomeCare offers non-medical personal care, home health and hospice services across 22 states. Allison said the company’s deal pipeline for 2025 is more robust than in previous years.
“Over the past couple of years, the acquisition opportunities that meet our strategic objectives have been somewhat limited due to some unfavorable market conditions. However, we are starting to see a few more opportunities that could strengthen all three of our segments in markets where we currently operate,” Allison said.
The renewed interest in deal-making could revive a buying frenzy in home care that began in 2021 and continued into 2023. Humana purchased Kindred at Home for $8.1 billion in 2021 and later rebranded it CenterWell. In February 2023, UnitedHealth Group acquired LHC Group for $5.4 billion and struck a deal to buy Amedisys for $3.3 billion four months later.
But higher interest rates, rising labor costs and the Justice Department’s scrutiny of the UnitedHealth-Amedisys deal put a damper on acquisitions in the second half of 2023 and the first half of this year, analysts said. In the first three quarters of 2024, home care acquisitions declined 25% compared to the same period last year, according to healthcare advisory firm Mertz Taggart.
In the past few months, lower interest rates have helped spark renewed interest in acquisitions, Mertz Taggart managing partner Cory Mertz said in a third quarter industry report.
The Trump administration and a Republican-controlled Congress could also help drive deals in the new year, Andrew Woods, chairman of consulting firm Liberty Partners Group told members of the National Alliance for Care at Home during a recent webinar. Woods said both might see home care as a less expensive alternative to facility-based care and encourage policies that drive more care to where people live.
“They understand, if they are old school Republicans, that deficits and debt matter. They’ll want to do everything they can to shore up the Medicare trust fund, not only with efficient services like home health, but other services in healthcare that can serve Baby Boomers,” Woods said.
The Justice Department’s lawsuit to block the bid from UnitedHealth Group’s Optum to buy Amedisys is a wild card that could disrupt deals in 2025, though some analysts don’t expect the suit will continue after President-elect Trump takes office.
Giesting also said the lawsuit could be dismissed by a new administration — and added most home care companies probably won’t make deals large enough to raise antitrust concerns in a highly fragmented industry.
Addus HomeCare, Aveanna and the Pennant Group did not respond to requests for comment on whether the lawsuit would affect their acquisition plans.
Large home care providers including Addus HomeCare, Aveanna Healthcare and the Pennant Group said during third quarter earnings calls they would aggressively look for deals next year to gain scale and better compete for hospital referrals.
Acute care hospitals received over $190 million in improper Medicare payments for outpatient hospice services, government watchdogs say.
An audit report released Monday by the US Department of Health and Human Services Office of Inspector General sampled over $283.7 million in Medicare Part B payments for outpatient services furnished by acute care hospitals to hospice patients from 2017 through 2021. The audit found that 70 out of the 100 services sampled by the agency did not comply with federal requirements.
The OIG noted in the audit that payments were made to acute-care hospitals for palliative care that were “already covered as part of the hospices’ per diem payments and should have been provided directly by the hospices or under arrangements between the hospices and acute-care hospitals.”
The OIG claims that this occurred due to factors including not having enough details in Medicare guidance, Medicare contractors not conducting prepayment and post-payment reviews, and not having a properly designed prepayment edit process.
Based on the sample, the OIG estimates that Medicare “could have saved $190.1 million” if “payments had not been made to acute-care hospitals that provided outpatient services to hospice enrollees for services related to the palliation and management of the enrollees’ terminal illnesses and related conditions.”
Additionally, the OIG estimated that enrollees “could have saved $43.6 million in deductibles and coinsurance that may have been incorrectly collected.”
The OIG made six recommendations to the Centers for Medicare & Medicaid Services, including improving system edit processes; educating hospitals to discern whether outpatient services palliated or managed conditions related to enrollees’ terminal illnesses; and clarifying Medicare guidance to specifically mention “related conditions.”
The CMS agreed with five of six recommendations but did not agree with the OIG’s first recommendation. The agency said it was concerned about the feasibility and effectiveness of the OIG’s proposed modifications to the system edits described in the report.
After reviewing the CMS’s comments, the OIG updated its first recommendation to the CMS’s system edit processes to help reduce improper payments in the future.
Sens. Bill Cassidy and Maggie Hassan are set to release a framework for Medicare site-neutral payment reforms as early as Friday.
Why it matters: Changes to the way hospitals are paid for outpatient procedures could be on the agenda in a lame duck session, and this framework fleshes out more options.
What’s inside: The framework is slated to be more expansive than some previous site-neutral policies and could look similar to what’s been proposed in the June 2023 MedPAC report.
While the hope is to get the framework out by Nov. 1, the timeline could slip. The goal is to release it before the election though, sources said.
The big picture: Hassan has previously been a leader on site-neutral payments with her SITE Act, but Cassidy’s involvement adds an influential Republican, who could potentially be HELP chair next year.
As Congress weighs the future of CMS’ Acute Hospital Care at Home Program (AHCAH), advocates are urging lawmakers to authorize a five-year extension, instead of another two-year plan, to bolster currently limited hospital and Medicaid participation. Advocates say CMS guidance, practitioner flexibilities and heightened commercial coverage of hospital-at-home programs would also further support AHCAH participation.
A key lobbyist previously told Inside Health Policy a five-year extension of AHCAH is more likely to appear in an end-of-year legislative package than a shorter extension, citing indications from Senate Finance Chair Ron Wyden (D-OR)’s staff that the senator supports a five-year extension.
Both the House Ways & Means and Energy & Commerce committees advanced legislation extending the hospital-at-home initiative by five years. Lawmakers are also poised to authorize a two-year extension of Medicare telehealth flexibilities that have helped hospitals operate AHCAH programs and meet the requirement of giving patients 24/7 access to either in-person or virtual nursing care.
As of Oct. 21, CMS has authorized 368 hospitals –about 6% of all U.S. hospitals identified by the American Hospital Association–to operate AHCAH programs.
Additional CMS data suggest only a portion of those AHCAH-approved hospitals offer inpatient care in patients’ homes; just 105 out of 284 or about 37% of AHCAH-approved hospitals in 2022 reported at least one discharge through the program, according to a June 2024 report from Medicare Payment Advisory Commission.
Hospital staffers told MedPAC they struggled to start AHCAH programs because of uncertainty about the future of the CMS program, start-up costs, a lack of institutional support and workforce needs.
Meanwhile, Medicaid programs in 12 states – Oregon, Arizona, Texas, Oklahoma, South Dakota, Arkansas, Michigan, New York, Massachusetts, North Carolina, South Carolina and Florida – cover hospital-at-home services as of Sept. 30, Pippa Shulman, chief medical officer of Medically Home, told IHP. She said several state Medicaid programs are waiting for a congressional reauthorization of the AHCAH program before covering hospital-at-home services.
Shulman, along with the Bipartisan Policy Center, American Hospital Association and other groups, predict a five-year reauthorization would go further toward supporting hospital and Medicaid participation in the AHCAH program than a two-year extension.
A five-year AHCAH extension “can provide additional time for hospitals and health systems to make the necessary investments to stand up some of these programs and to also provide additional time to evaluate the results,” Jennifer Holloman, AHA’s senior associate director of policy, told IHP.
However, even with a lengthier AHCAH extension, hospital-at-home supporters say policymakers should support hospital uptake through guidance and practitioner flexibilities.
Additional CMS Support
In a July 2024 report, the Bipartisan Policy Center called on Congress to authorize funding for CMS to provide technical assistance to support hospitals and Medicaid agencies participating in the AHCAH program.
The technical assistance could include best practices for operating AHCAH programs and patient risk assessment screenings, BPC wrote. At the same time, BPC recommended CMS “strengthen regulatory guidance” with documents on escalation protocols for clinical deterioration, fall prevention, infectious prevention practices and the efficient use of telehealth and remote patient monitoring.
A CMS spokesperson said the agency has already “established a process to maintain the health and safety standards of care” for AHCAH, including guidance for hospitals “when there is evidence that there are clear gaps in communication and coordination of care that may lead to patient safety concerns.” They added the agency readily provides technical assistance to help facilities apply for AHCAH waivers at every stage of the application process.
The spokesperson did not comment on whether CMS sees a need for additional guidance and technical assistance to support hospital and Medicaid participation in the AHCAH program.
Holloman of AHA said CMS could continue to provide resources supporting upfront costs hospitals face when starting AHCAH programs. She added CMS could work with other agencies on policies supporting AHCAH programs such as expanding broadband internet access.
Congress has yet to reauthorize billions of dollars to an expired program expanding broadband internet access to low-income Americans through subsidies.
Practitioner Flexibilities
Aside from new CMS guidance, some hospital staffers say they would like additional types of practitioners to be allowed to care for patients in their homes.
Darcy Harris, physician executive director of Yale New Haven Health System clinical operations, said she would like Connecticut to allow community paramedics to care for patients in their homes. Community paramedics can care for AHCAH patients across the border in Massachusetts.
Allowing new types of practitioners to deliver acute care in patients’ homes “could help overcome barriers for more rural hospitals to participate in” the AHCAH program, wrote Allison Buffett, a senior policy analyst for BPC’s health program.
“However, it’s crucial to better understand why and how hospitals are adjusting their staffing to provide acute care at home and how these modifications impact the care quality, operational costs, and, most importantly, patient outcomes,” she wrote.
BPC has recommended CMS write a report to Congress on the cost and quality of AHCAH programs by September 2028 that includes staffing metrics and qualitative workforce data.
The CMS spokesperson noted that AHCAH-authorized hospitals cannot admit patients if they don’t also comply with state licensure requirements.
Commercial Coverage
Holloman of AHA and Collen Hole, innovation strategic advisor for AdvocateHealth, argue a five-year extension of the AHCAH program would also expand commercial coverage of hospital-at-home services. A permanent extension after the five years would go even further in unleashing commercial coverage, Holloman added.
Increased commercial coverage of hospital-at-home services could help hospitals pay for costly programs. Within one hospital, there could be Medicare beneficiaries who are eligible for hospital-at-home services but also patients with private insurance ineligible for such services, explained Mona Siddiqui, senior vice president of home & community services for Highmark Health.
“CMS may pay for hospital-at-home, but how are other payers paying for that as well?” Siddiqui asked.
Still, increased commercial coverage of hospital-at-home services alone wouldn’t solve every payment problem hospitals face.
Hole raised concerns that commercial payers are paying less for hospital-at-home services than services offered at hospitals because data, including some from CMS, suggest hospital-at-home programs reduce health care costs. But that line of thinking ignores the fact hospitals are currently struggling to pay for the high start-up costs for hospital-at-home programs, she said.
Siddiqui, meanwhile, noted while the AHCAH program covers hospital-at-home services, CMS does not cover skilled nursing facility services at home.
Some health systems are pausing, scrapping or delaying the launch of hospital-at-home programs despite a broader industry push to provide more healthcare in the home.
Health systems such as Tufts Medicine, Franciscan Health, Cone Health and UCSF Health pointed to high costs, a shortage of eligible patients and regulatory uncertainty as driving their decisions to curtail home-based hospital programs. But despite the hurdles, others are moving full-speed ahead with new programs or expansions.
CMS began letting health systems provide hospital-level care to patients where they live in March 2020 to free up beds during the COVID-19 pandemic. Under the Acute Hospital Care at Home waiver, Medicare reimburses hospitals at the same rate for home-based acute care as it does for care in a facility. The waiver expires at the end of December and Congress must decide to extend or end it.
The agency has approved 366 waivers across 138 health systems as of Oct. 10, according to a CMS spokesperson. While a CMS report released last month gave hospital-at-home a mostly positive review, health systems may not be actively enrolling patients or have suspended their programs for a variety of reasons.
Some health systems that received CMS waivers never even got their hospital-at-home programs off the ground.
University of California San Francisco Health scrapped plans to launch a program in May 2023 because the California Department of Health Care Services stopped licensing at-home acute care programs when the federal public health emergency expired, said Dr. Timothy Judson, the health system’s medical director of care delivery transformation.
Judson said in an email he still hopes to launch hospital-at-home because the health system doesn’t have enough beds.
“If the CMS waiver is extended, I certainly do hope that California will create a pathway for [hospital-at-home],” Judson said.
Greensboro, North Carolina-based Cone Health got a waiver from CMS in July 2022 to launch a program at Moses H. Cone Memorial Hospital in Greensboro, but is still in a planning phase, said a hospital spokesperson, who would not provide additional details on when or if Cone Health might launch a program.
Other health systems have backed away from plans to scale their hospital-at-home programs due to regulatory uncertainty.
For example, Franciscan Health in Crown Point, Indiana, launched its hospital-at-home program in 2021. An expansion is on hold until the system has more clarity on the federal waiver, as well as state licensing and accreditation requirements, according to a spokesperson.
Some health systems that launched programs when the COVID-19 pandemic created a huge influx of patients are finding it difficult to expand them as patient demand for care has returned to pre-pandemic levels.
That’s been a problem for St. Bernards Medical Center in rural Jonesboro, Arkansas. The health system launched its AcuteHealth at Home program in March 2021 with plans for it to grow, said a hospital spokesperson. While the program continues, St. Bernards paused an expansion because it can’t find enough eligible patients who live within 30 minutes of the hospital, as required under the federal waiver.
The costs of launching and scaling acute care-at-home programs can also be a challenge, given the financial resources required for the technology, staffing and ancillary services necessary to support home hospital programs.
Tufts Medicine paused its hospital-at-home pilot at Lowell General Hospital in Lowell, Massachusetts, last year due to financial constraints, a spokesperson said. The health system “remained confident in the benefits of the program,” but decided to focus its resources on a mobile integrated health program and a program directed at patients with complex health needs. The spokesperson said those programs are better at decreasing avoidable hospital admissions.
Executing hospital-at-home is difficult for some health systems, said Pippa Shulman, chief medical and strategy officer of Medically Home. The Boston-based company partners with health systems to provide the technology platform and some staffing for home-based hospital programs.
She said some health systems are able to provide 24/7 care at a small scale when they launch hospital-at-home programs, but struggle to provide services as they expand.
“You need to be able to [to provide care] for five patients, for 10 patients, and for 50 patients from when you start,” Shulman said. “That is the moral imperative. You have to make sure you deliver safe and effective care. You want people to tread carefully before they do this. It’s a big step.”
Even some health systems with successful hospital-at-home programs have encountered hurdles.
The University of Arkansas for Medical Sciences launched an acute care-at-home program last year at the UAMS Medical Center in Little Rock, Arkansas, in partnership with Contessa Health, a division of home health company Amedisys. The medical center has cared for approximately 200 patients at home during the first year of the program, but staffing has sometimes been a challenge, UAMS Medical Center CEO Dr. Michelle Krause said in an email.
“We have physicians available for video conferencing with patients, but Contessa has had difficulties securing nurses to visit patients and deliver supplies,” Krause said.
In an email, a Contessa spokesperson said nurses are vital to home-based care, but admitted staffing can be difficult. “No hospital-at-home program is immune from this constraint. Having a reliable partner in the nurse staffing arena doesn’t remove the hurdle, but significantly mitigates the headwind,” the spokesperson said.
Despite the challenges, some health systems still view hospital-at-home as a safe, viable and economical alternative to facility-based acute care.
AdventHealth Orlando is weeks away from launching its first hospital-at-home program, a year after receiving a CMS waiver, according to a spokesperson.
Advocate Health is also bullish on the concept. It offers hospital-at-home to patients at 10 Atrium Health hospitals in North Carolina. Atrium launched its first program in 2020 and expanded hospital-at-home prior to its merger with Advocate Aurora Health, said Colleen Hole, AdvocateHealth innovation strategic advisor. Hole said the health system has treated approximately 13,000 patients across North Carolina so far and is eager to expand the program to other states.
“To continue to build beds, which costs between $2 million and $5 million dollars per bed, is not cost-effective,” Hole said. “This model has proven that it will deliver excellent care without the time and expense of building [brick-and-mortar facilities].”
Patients who receive hospital care at home generally have lower mortality rates than their brick-and-mortar inpatient counterparts, according to a Centers for Medicare and Medicaid Services report on the Acute Hospital Care at Home initiative.
CMS said it’s difficult to conclude that the Acute Hospital Care at Home initiative resulted in lower Medicare spending overall as compared to brick-and-mortar inpatient care.
The COVID-19 initiative was extended past the end of the public health emergency, but is scheduled to expire at the end of this year. Congressional action is needed to extend the Acute Hospital Care at Home waivers.
The American Hospital Association supports the Hospital Inpatient Services Modernization Act, a bill that extends the waivers for five years through the end of 2029.
As of June, 331 hospitals, across 136 systems and 37 states, had been approved to provide acute hospital services to patients at home.
WHY THIS MATTERS
The CMS study examined the quality of care for patients treated in the inpatient hospital setting, as compared to individuals with similar conditions and characteristics treated at home. AHCAH patients were found to be meaningfully different from inpatients receiving services furnished by the same hospital facility, CMS said.
In general, AHCAH patients were more likely to be white and live in an urban location and less likely to receive Medicaid or low-income subsidies.
These different characteristics of the AHCAH population may be partially attributable to the inclusion and exclusion criteria developed by participating hospitals for the purpose of identifying patients appropriate for Hospital at Home care, CMS said.
CMS specifically looked at 30-day mortality rates, 30-day readmission rates, and Hospital Acquired Conditions. The study found that beneficiaries who received care under the hospital at home initiative generally had a lower mortality rate than their brick-and-mortar inpatient comparison counterparts.
Results of the 30-day readmissions metric analysis demonstrated some differences, with readmission rates being significantly higher in the acute care at home group for two MS-DRGs, but significantly higher in the inpatient comparison group for three MS-DRGs.
Hospital acquired condition rates observed for beneficiaries served for patients at home were lower than HAC rates observed in the brick-and-mortar inpatient comparison group for all six types of HACs evaluated, though the differences in these rates were not statistically significant, CMS said.
Patients in AHCAH were primarily treated for a relatively small set of conditions. The study found that the most common Medicare Severity Diagnostic Related Groups (MS-DRGs) and Major Diagnostic Categories (MDCs) treated through the AHCAH initiative included respiratory conditions, circulatory conditions, renal conditions and infectious diseases.
COST
The study focused on select metrics, including length of stay per episode, the Medicare spending in the 30 days after hospital discharge and hospital service utilization, including services provided in-person and virtually through telehealth.
The analysis shows that acute care at home inpatient episodes had, on average, a slightly longer length of stay than comparable brick-and-mortar inpatient episodes.
Additionally, there was, on average, lower Medicare spending for services furnished in the 30-day post-discharge period for at-home episodes, as compared to brick-and-mortar inpatient episodes, across more than half of the top 25 MS-DRGs in the acute care at home group.
The differences attributable to hospital at home 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.
PATIENT EXPERIENCE
CMS hosted four virtual listening sessions with patients and caregivers and collected anecdotal information through site visits, direct correspondence with patients and hospital program operators.
Overall, patients and caregivers had positive experiences with the care provided in the home setting. This positive feedback was mirrored by clinicians’ experiences providing care to patients at home, CMS said.
THE LARGER TREND
CMS said its study offers new insights and lessons learned for quality improvement efforts for the health and safety of inpatients in the home setting. It also offers opportunities to further develop more targeted measures of cost, quality and utilization.
Acute Hospital Care at Home waivers went into effect during the COVID-19 public health emergency. The Consolidated Appropriations Act, 2023 extended the waivers and flexibilities until the end of this year.
The CAA required CMS to conduct a study and analysis on the initiative and post such a report on a CMS website by September 30.
State Medicaid programs across the country failed to promote access to health-care services that could have supported better maternal and infant health outcomes, a federal watchdog agency said.
A report released this week by the US Department of Health and Human Services Office of Inspector General surveyed managed care organizations across 41 state Medicaid programs.
The watchdog found many states didn’t fully leverage Medicaid managed care coverage and access requirements to promote access to maternal health care. The report said many states didn’t require their managed care organizations (MCOs) to cover important types of maternal health providers.
The report comes as the US grapples with some of the worst maternal health outcomes in the developed world. The Centers for Disease Control and Prevention estimates American mothers die at a rate of 22.3 deaths per 100,000 live births, with non-Hispanic Black women fairing considerably worse, averaging 49.5 deaths under the same metric.
In contrast, Denmark, which has a similar GDP per capita as the US, averaged 4.7 deaths per 100,000 births.
The report also highlighted that some states didn’t require their MCOs to cover certified nurse-midwives, freestanding birth centers, and maternal-fetal medicine specialists even though Medicaid requires that states cover these providers if they are licensed or otherwise recognized by the state.
Only one state out of the 41 queried reported it requires its MCOs to cover all four types of health professionals whose services are optional Medicaid benefits (lactation consultants, community health workers, doulas, and non-nurse midwives) the watchdogs asked about in the survey.
The OIG recommended the Centers for Medicare & Medicaid Services take steps to ensure that all states cover required maternal health services for people enrolled in MCOs.
The watchdog also asked the CMS to clarify states’ requirements to maintain network adequacy standards for OB/GYNs and that the agency support states in tailoring their network adequacy standards to better address maternal health-care needs. Those standards can also include appointment wait times and distance standards.
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