Lobbyists Confront Challenges In Hospital At Home Push

August 29, 2023 2:29 pm

August 24, 2023 7:03PM ET

(Inside Health Policy)

As health systems press state and federal policymakers to continue coverage of CMS’ Acute Care at Home program beyond 2024, bigger questions are brewing as to what a permanent coverage program should look like.

At issue for setting a long-term hospital at home coverage program is what payment model should be used, and how to achieve standard measures of quality and outcomes to assess the programs. Then, there are the seemingly unending questions on how the federal program interacts with standing state regulations on hospital beds, certificate of need laws and state Medicaid programs.

While lobbying states and CMS, health systems are also working with commercial payers to continue the programs regardless of Medicaid or Medicare coverage due to the ongoing capacity crises in hospitals and cost savings achieved through the program.

A 2020 waiver by CMS allowed hospitals to apply for the Acute Care at Home program, which let the health care organizations provide in-patient-level care to patients at home to offset the droves of COVID-19 patients inhabiting hospital beds. Hospitals at home typically combine home visits by health care professionals, telehealth visits, and remote monitoring devices to care for acute conditions. Congress extended the waiver through Dec. 31, 2024, and called for HHS to conduct a study comparing the quality and quantity of services as well as the clinical conditions of patients served in inpatient and home settings.

Though CMS gave hospitals the green light on the programs — which shortened patient stays and improved mental health — much of the actual implementation hinged on whether state Medicaid programs decided to cover it, as the CMS waiver did not require them to.

Few states opted to cover hospital at home programs. Colleen Hole, vice president of clinical integration and chief nurse executive at Atrium which runs the nation’s largest hospital at home program, told Inside TeleHealth that only nine or 10 hospital at home Medicaid waivers exist.

North Carolina Medicaid, where Atrium is located, toggled back and forth during the public health emergency on whether to cover the program and provided coverage in spurts. Ultimately, NC Medicaid stopped paying for the program in March 2022 for nebulous reasons, but it began reconsidering data in November 2022.

In recent weeks, Hole has advocated for Medicaid coverage on a call with Medicaid officials and other stakeholders. Atrium is leveraging a health equity argument for coverage of the hospital at home program, saying that going into the home helps health care professionals understand a patient’s social drivers of health like access to food or other living conditions.

Hospital at home could be an enduring model for providing acute patient care and decrease pressure on hospital bed capacity, advocates of the program also say.

However, policymakers must answer fundamental questions on payment, standard of care, and how to count the virtual hospital beds within the state’s allotted bed count.

“Here we are with just about 18 months or less to go. And so we’re trying desperately to continue those conversations with state and federal supporters. And honestly, I don’t know what’s going to happen. I don’t think anybody does,” Hole said.

States regulate hospital bed licenses and certificate of need (CON) laws govern when and how more hospitals should be built in a state. Hole said state regulators are unclear whether the virtual in-patient beds count towards a hospital’s total bed count and if CON law should even apply to hospital at home.

Moreover, there are also questions about how the program should be paid for. While during the public health emergency hospital at home was paid for through DRG (diagnostic related group) payment, some say the program should fall to CMS’ innovation center as a pilot program moving forward. Others argue for a 30-day or bundled payment model, but Hole says payers and hospitals both would not understand how to process the claims.

Moreover, the program needs to produce robust data to convince CMS of its merit and create standard definitions and outcome measures to assess existing and new programs. A collection of health systems are working on this front to develop a database, including UMass, Mount Sinai, Mayo Clinic, Atrium and Intermountain. Moreover, the industry needs to “create common language, common metrics, and outcome targets,” she said.

CMS and states have a host of issues to untangle to create an effective hospital at home care model to last beyond COVID-19 waivers, but whether federal and state governments can sort out the issues in time for a new program to be established by the end of December 2024 will not deter Atrium from surging ahead.

“Whether it passes or not, we still have a significant capacity problem here in our market. We’re in a growing market in North Carolina. So we’ve got to create acute care capacity one way or another. And, you know, we are still building some hospitals. But this is absolutely part of our strategy to scale to 100 and probably even 200 and maybe beyond in-patient beds,” Hole said.

Atrium has been working with commercial payers to establish a long-term program — one that wouldn’t be as legally complicated as CMS’ wavier.

“If we lose CMS funding, both Medicare and Medicaid never pay, we will continue to work with commercial payers. But the model will look a little bit different. We’ll still be delivering hospital level care. But quite frankly, we get out from under some of the rigidity of the waiver. And have more flexibility in where the patient can come from. They can come from their own home without having to come to a hospital to go back home. They can come from a doctor’s office. So we’re doing that really in parallel to our current CMS waivered inpatient programs,” Hole said.

Without CMS’ definition that hospital at home programs are technically in-patient programs, health systems could avoid state bed licensure issues and certificate of need laws, Hole said. Other clunky requirements could also disappear, such as a patient having to go into a hospital before being transferred to the hospital at home program.

Hole predicts CMS ultimately will do another extension of the current Acute Care at Home program because the agency and industry do not have enough time to come up with a vetted and thorough program by next December. — Emma Beavins (ebeavins@iwpnews.com)