Providers are bypassing Medicare requirements to set up scaled-down hospital-at-home programs they say save money by reducing hospitalizations.
Ochsner Health, Los Angeles General Medical Center and TRU PACE in Colorado are among those offering home-based hospital programs that are less expensive and quicker to set up than the Acute Hospital Care at Home program, which has an uncertain future. Providers say the programs free up hospital beds for sicker patients and save money by keeping some patients in risk-based care plans out of the hospital. However, most of the in-home hospital programs donât have the rigorous guardrails mandated in the Medicare waiver program.
Delivering hospital-level care in the home makes sense if patients prefer it, it’s safe and it’s cost-effective, said Matthew Notowidigdo, a healthcare economics professor at the University of Chicagoâs Booth School of Business who studies hospital-at-home. However, he said the savings generated by these programs should not dictate where a patient receives care.
âThere is always a concern that the insurers are going to respond to those incentives and try to manipulate the system in a way that is not great for patients,â Notowidigdo said.
The Medicare Acute Hospital Care at Home program requires hospitals to send nurses to patientsâ homes twice a day, remotely monitor them at all times, provide meals and provide some nonmedical services for two to five days. Medicare reimburses at the same rate for hospital-at-home as it does for a facility stay. The Centers for Medicare and Medicaid Services has approved waivers for nearly 380 hospitals, but some havenât launched hospital-at-home programs because they can be costly and hard to scale.
Those were among the reasons New Orleans-based Ochsner Health opted not to apply for the Medicare waiver, said Dr. Logan Davies, medical director of hospital access and throughput at Ochsner Medical Center. Instead, the nonprofit health system partnered last year with myLaurel, a New York-based home healthcare company, to offer its own hospital-at-home program called Acute Care at Home.
Davies said approximately 500 patients enrolled in the program last year and they had fewer emergency room visits and hospital admissions, which resulted in a $1,400 return on investment per enrollee.
Patients enrolled in Ochsnerâs accountable care organization are eligible for the program and get referred to it from the emergency room. Then myLaurel sends a nurse or paramedic to the patientâs home within a day of admission and provides additional visits over a 15-day period, depending on the patientâs condition. Patients also receive supplemental telehealth support and prescriptions.
myLaurel bills Ochsner a flat fee for the first home visit and bundles fees for other services based on a patientâs length of stay, said Lisa Sasko, myLaurelâs chief growth officer.
Ochsner launched the program in March at its flagship medical center in New Orleans and expanded it to three more hospitals over the last two months. Davies said the system’s program is more flexible, and allows the system to provide only the services patients actually need.
âWe can gauge what the patientâs clinical needs are and spec out a care delivery program that is specific to that patientâs condition,â Davies said.
The Medicare waiverâs rigid requirements â particularly the twice-daily nurse visits âprompted Los Angeles General Medical Center to develop its all-virtual Safer@Home program in 2020, said Dr. Brad Spellberg, the hospitalâs chief medical officer.
âWe donât have enough staff to be sending them all over the county of Los Angeles,â Spellberg said.
Safer@Home provides home-based hospital care to eligible patients, who are mostly uninsured or on Medicaid. Patients receive virtual clinical visits, remote vital sign monitoring and oral or inhaled medications rather than intravenous therapy. Nurses and physicians are on hand for virtual care 12 hours a day, 7 days a week. Patients are released from the program when their conditions either improve or escalate, requiring in-person care.
In a study published last year in JAMA Network Open, Los Angeles General found patients enrolled in Safer@Home were released from care sooner than similar patients with in-facility stays and were less likely to return to hospital emergency rooms within 30 days of discharge.
Spellberg said Los Angeles General enrolls about three patients a day on average in the program and bears all costs for its patients. He said even with that expense, the health system still comes out ahead financially.
âIt is expensive to be in the hospital and Medicaid reimburses below the cost of a hospital stay, so it is actually a cost savings for us to send people home if they have Medicaid,â said Spellberg. “We need those beds for patients with traumas, heart attacks and strokes.”
Another limitation of the Medicare waiver is that only hospitals can participate in Acute Hospital Care at Home.
DispatchHealth, an in-home medical treatment company, lets value-based care providers and health plans admit patients directly to its Hospital-Alternative Care program without visiting a hospital. The Denver-based company offers the program in seven mostly western cities and has treated approximately 3,500 patients since it launched in 2019, said a spokesperson.
âOur readmission rate is 8.4% where the industry average is about 20%,â Diana Verrilli, DispatchHealthâs chief growth officer, said. âFrom a payer lens that is significant in terms of the ability to keep that patient out of the hospital for any exacerbation that they may have.â
Patients receive either in-person or virtual nurse visits daily, remote monitoring, lab work, intravenous medications, meals and physical therapy for up to 30 days at home.
DispatchHealth charges value-based care organizations and health plans a negotiated rate for an entire episode of care based on the patientâs condition, said Verrilli.
TRU PACE in Lafayette, Colorado, has been using the Hospital-Alternative Care program for about four years for some elderly adults in the PACE program. TRU PACE takes on full-risk for Medicare and Medicaid dually-elgible older adults who get health services at home and in a neighborhood center. The nonprofit could not provide an estimate on how much the Hospital-Alternative Care program has saved the organization, but medical director Dr. Lisa-Marie Brown said it has resulted in fewer hospitalizations for patients with congestive heart failure, chronic obstructive pulmonary diease and other infections.
âSometimes patients are kept [in the hospital] longer than they need to be and they can decline because they arenât in their own beds or their own environment. There is also increased risk for delirium,â Brown said.
Last Updated On: January 28, 2025
Hospital-at-home alternatives score with some providers
modernhealthcare.com
January 28, 2025 9:42 am
Providers are bypassing Medicare requirements to set up scaled-down hospital-at-home programs they say save money by reducing hospitalizations.
Ochsner Health, Los Angeles General Medical Center and TRU PACE in Colorado are among those offering home-based hospital programs that are less expensive and quicker to set up than the Acute Hospital Care at Home program, which has an uncertain future. Providers say the programs free up hospital beds for sicker patients and save money by keeping some patients in risk-based care plans out of the hospital. However, most of the in-home hospital programs donât have the rigorous guardrails mandated in the Medicare waiver program.
Delivering hospital-level care in the home makes sense if patients prefer it, it’s safe and it’s cost-effective, said Matthew Notowidigdo, a healthcare economics professor at the University of Chicagoâs Booth School of Business who studies hospital-at-home. However, he said the savings generated by these programs should not dictate where a patient receives care.
âThere is always a concern that the insurers are going to respond to those incentives and try to manipulate the system in a way that is not great for patients,â Notowidigdo said.
The Medicare Acute Hospital Care at Home program requires hospitals to send nurses to patientsâ homes twice a day, remotely monitor them at all times, provide meals and provide some nonmedical services for two to five days. Medicare reimburses at the same rate for hospital-at-home as it does for a facility stay. The Centers for Medicare and Medicaid Services has approved waivers for nearly 380 hospitals, but some havenât launched hospital-at-home programs because they can be costly and hard to scale.
Those were among the reasons New Orleans-based Ochsner Health opted not to apply for the Medicare waiver, said Dr. Logan Davies, medical director of hospital access and throughput at Ochsner Medical Center. Instead, the nonprofit health system partnered last year with myLaurel, a New York-based home healthcare company, to offer its own hospital-at-home program called Acute Care at Home.
Davies said approximately 500 patients enrolled in the program last year and they had fewer emergency room visits and hospital admissions, which resulted in a $1,400 return on investment per enrollee.
Patients enrolled in Ochsnerâs accountable care organization are eligible for the program and get referred to it from the emergency room. Then myLaurel sends a nurse or paramedic to the patientâs home within a day of admission and provides additional visits over a 15-day period, depending on the patientâs condition. Patients also receive supplemental telehealth support and prescriptions.
myLaurel bills Ochsner a flat fee for the first home visit and bundles fees for other services based on a patientâs length of stay, said Lisa Sasko, myLaurelâs chief growth officer.
Ochsner launched the program in March at its flagship medical center in New Orleans and expanded it to three more hospitals over the last two months. Davies said the system’s program is more flexible, and allows the system to provide only the services patients actually need.
âWe can gauge what the patientâs clinical needs are and spec out a care delivery program that is specific to that patientâs condition,â Davies said.
The Medicare waiverâs rigid requirements â particularly the twice-daily nurse visits âprompted Los Angeles General Medical Center to develop its all-virtual Safer@Home program in 2020, said Dr. Brad Spellberg, the hospitalâs chief medical officer.
âWe donât have enough staff to be sending them all over the county of Los Angeles,â Spellberg said.
Safer@Home provides home-based hospital care to eligible patients, who are mostly uninsured or on Medicaid. Patients receive virtual clinical visits, remote vital sign monitoring and oral or inhaled medications rather than intravenous therapy. Nurses and physicians are on hand for virtual care 12 hours a day, 7 days a week. Patients are released from the program when their conditions either improve or escalate, requiring in-person care.
In a study published last year in JAMA Network Open, Los Angeles General found patients enrolled in Safer@Home were released from care sooner than similar patients with in-facility stays and were less likely to return to hospital emergency rooms within 30 days of discharge.
Spellberg said Los Angeles General enrolls about three patients a day on average in the program and bears all costs for its patients. He said even with that expense, the health system still comes out ahead financially.
âIt is expensive to be in the hospital and Medicaid reimburses below the cost of a hospital stay, so it is actually a cost savings for us to send people home if they have Medicaid,â said Spellberg. “We need those beds for patients with traumas, heart attacks and strokes.”
Another limitation of the Medicare waiver is that only hospitals can participate in Acute Hospital Care at Home.
DispatchHealth, an in-home medical treatment company, lets value-based care providers and health plans admit patients directly to its Hospital-Alternative Care program without visiting a hospital. The Denver-based company offers the program in seven mostly western cities and has treated approximately 3,500 patients since it launched in 2019, said a spokesperson.
âOur readmission rate is 8.4% where the industry average is about 20%,â Diana Verrilli, DispatchHealthâs chief growth officer, said. âFrom a payer lens that is significant in terms of the ability to keep that patient out of the hospital for any exacerbation that they may have.â
Patients receive either in-person or virtual nurse visits daily, remote monitoring, lab work, intravenous medications, meals and physical therapy for up to 30 days at home.
DispatchHealth charges value-based care organizations and health plans a negotiated rate for an entire episode of care based on the patientâs condition, said Verrilli.
TRU PACE in Lafayette, Colorado, has been using the Hospital-Alternative Care program for about four years for some elderly adults in the PACE program. TRU PACE takes on full-risk for Medicare and Medicaid dually-elgible older adults who get health services at home and in a neighborhood center. The nonprofit could not provide an estimate on how much the Hospital-Alternative Care program has saved the organization, but medical director Dr. Lisa-Marie Brown said it has resulted in fewer hospitalizations for patients with congestive heart failure, chronic obstructive pulmonary diease and other infections.
âSometimes patients are kept [in the hospital] longer than they need to be and they can decline because they arenât in their own beds or their own environment. There is also increased risk for delirium,â Brown said.