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The U.S. Centers for Medicare & Medicaid Services’ (CMS) Acute Hospital Care at Home waiver was a major boost for organizations hoping to implement or expand hospital-at-home programs.
As of Nov. 21 2023, 305 hospitals and 129 health systems in 37 states have been approved to provide hospital-at-home care under the CMS waiver program.
Still, it was never meant to be permanent. With this in mind, some are wondering if state Medicaid agencies could be a way to further the hospital-at-home movement.
“For hospital at home to really scale, having a robust multi-payer environment that includes Medicare, Medicaid, commercial insurers and [Medicare Advantage] is really going to be necessary,” Dr. Bruce Leff, a professor of medicine and director of the center for transformative geriatric research at Johns Hopkins University School of Medicine, told Home Health Care News. “The more payers that we can get into the mix, the better.”
Right now, only nine state Medicaid programs reimburse for hospital at home. There are a number of reasons why.
In the eyes of some Medicaid officials, hospital at home is still a relatively new care delivery model, according to Leff.
“Administering a program like Medicaid is not an easy job,” he said. “I think they want to be sure that they are safeguarding beneficiaries, and also being good stewards of the tax dollar.”
There’s sometimes a general impression that hospital at home can’t serve people who are Medicaid eligible.
Leff noted that in the past, for example, he encountered the assumption that only people in wealthy Upper East Side neighborhoods of Manhattan utilized Mount Sinai Health System’s hospital-at-home program.
“In fact, when we looked at that data, what we found was that 40% of people treated in the Mount Sinai CMMI demonstration lived in New York City public housing,” he said. “We found that the advantages, in terms of reduced ED visits and rehospitalizations, actually were seen on the Medicaid eligible beneficiary side.”
Leff believes that this is because delivering care in people’s homes allows care teams to directly visualize social determinants of health, and then take action.
One other reason Medicaid state agencies may not be covering hospital-at-home is due to legislative and policy barriers, according Dr. Michael Chin, medical director for health information technology and clinical informatics at MassHealth.
“It varies by state, but some may determine that they need to pass a state law, or revise state regulations, or get their state department of public health to give approval before hospital-at-home can be covered,” he told HHCN.
Chin also pointed out that some states have requested more information and published data regarding hospital at home.
“We have heard other states say, ‘Oh, we want a little bit more evidence around hospital at home for us to feel comfortable doing more implementation efforts,’” he said.
Massachusetts closes the gap
Already known for providing robust long-term care services, Massachusetts is also one of the nine states that covers hospital at home through its state Medicaid program, MassHealth.
“In Massachusetts, we feel that we’ve closed the gap on this reimbursement mechanism,” Dr. Charles Pu, senior medical director of the office of long-term services and supports at MassHealth, told HHCN.
In March 2021, the state Medicaid agency issued Bulletin 56, which calls for all MassHealth managed care entities to cover hospital at home.
In September 2023, the state Medicaid agency issued another one — Bulletin 197 — which provided updated guidance, in particular around billing codes.
There have been over a thousand hospital-at-home admissions among MassHealth members, according to Pu.
Hospital-at-home programs in Massachusetts are also working under the CMS Acute Hospital Care at Home waiver.
In fact, over 15 hospitals in the state have approval for CMS’ waiver. Of these hospitals, five have launched their hospital-at-home programs, and are billing MassHealth.
“What’s striking is that in light of uncertainty — it’s not clear what CMS intends to do in terms of extending or changing the waiver after December 2024 — there’s this expansion of hospital at home,” Chin said. “We have five hospitals, but many more are either planning to launch within the next year, or they’ve already gotten approval from CMS. Also, in our conversations with some of the operating hospital-at-home programs in our state, they tell us they’re seeking to expand and move to scale.”
Chin and Pu believe that if all Medicaid state programs covered hospital at home, it would be a major accelerant for increased implementation and access to care.
“Medicaid is one of the two largest government payers in the U.S., and to have this payment alignment, across both Medicare and Medicaid, would really make this care accessible to a much larger swath of the population, including underserved populations,” Pu said.
That said, there are also larger consequences if more state Medicaid agencies choose to not engage with hospital at home, according to Leff.
“I think if Medicaid programs do not start to engage in hospital-at-home, then they are actually exacerbating inequity in health care delivery,” he said. “They’re making it more difficult for health systems to engage in a health care model that can help people. The lack of engagement of Medicaid programs affects not only Medicaid beneficiaries, but it affects non-Medicaid beneficiaries as well, to the extent that Medicaid is a major player in the health care delivery environment. What they do, and how they do it, signals to other payers and to health systems.”
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