As Congress weighs the future of CMSâ 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)âs 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 patientsâ 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 âcan 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,â Jennifer Holloman, AHAâs 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 âstrengthen regulatory guidanceâ 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 âestablished a process to maintain the health and safety standards of careâ for AHCAH, including guidance for hospitals âwhen there is evidence that there are clear gaps in communication and coordination of care that may lead to patient safety concerns.â 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 âcould help overcome barriers for more rural hospitals to participate inâ the AHCAH program, wrote Allison Buffett, a senior policy analyst for BPCâs health program.
âHowever, itâs 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,â 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 donât 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.
âCMS may pay for hospital-at-home, but how are other payers paying for that as well?â Siddiqui asked.
Still, increased commercial coverage of hospital-at-home services alone wouldnât 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.
As Congress Floats AHCAH Extension, Hospital And Medicaid Participation At Stake
Inside Health Policy
October 31, 2024 12:07 pm
As Congress weighs the future of CMSâ 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)âs 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 patientsâ 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 âcan 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,â Jennifer Holloman, AHAâs 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 âstrengthen regulatory guidanceâ 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 âestablished a process to maintain the health and safety standards of careâ for AHCAH, including guidance for hospitals âwhen there is evidence that there are clear gaps in communication and coordination of care that may lead to patient safety concerns.â 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 âcould help overcome barriers for more rural hospitals to participate inâ the AHCAH program, wrote Allison Buffett, a senior policy analyst for BPCâs health program.
âHowever, itâs 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,â 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 donât 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.
âCMS may pay for hospital-at-home, but how are other payers paying for that as well?â Siddiqui asked.
Still, increased commercial coverage of hospital-at-home services alone wouldnât 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.