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The one-year anniversary of the Centers for Medicare & Medicaid Services’ (CMS) “Acute Hospital Care at Home” announcement will land on Thanksgiving this year, Nov. 25.
And while there’s a lot for providers to be thankful for, there’s also a lot left to be sought after. After all, the end of the public health emergency (PHE) – which coincides with the waiver program – is looming.
Meanwhile, providers are putting in months of legwork to make their own programs viable.
UMass Memorial Health started its own hospital-at-home program late in the game this past August with the idea to take it slow. Even with the end of the PHE up in the air, the health system thought it was time to dig its feet in.
“We always had a goal of starting with a ‘crawl, walk, then run’ approach to admission,” Dr. Constantinos Michaleidis, the medical director of the hospital-at-home program at UMass Memorial Health, told Home Health Care News. “We’ve had an amazing early experience, … so I think over the next couple of months, my guess is that we’re going to start to ramp up.”
UMass Memorial is a nonprofit health care system located in central Massachusetts. Its network consists of more than 14,000 employees and 1,700 physicians.
Its program has admitted 75 or so patients thus far, and it has a daily census of anywhere from seven to nine patients. Currently, it takes one clinical team to take care of those patients.
Michaleidis believes two clinical teams will be assigned to the program in the near-term future, which will subsequently lead to more patients on census.
As of Nov. 15, there were 83 health systems and 187 hospitals in 34 states approved for the CMS waiver program. Both the challenges that come with hospital at home – and the aspirations for its future, post-PHE – are made evident by the many approved systems and hospitals not using the waiver at all.
“Over 200 hospitals submitted waivers to do hospital at home,” Dr. Amal Agarwal, the VP of home solutions for Humana (NYSE: HUM), told HHCN in September. “There’s a lot of interest. I have the benefit of practicing part time, and I’m seeing patients ask for it. … The question is, how many [hospitals] are actually doing it?”
Putting a program in place takes a lot of time and effort, which could be one of the reasons why all the hospitals that have been approved aren’t actually admitting patients yet, according to Rami Karjian, the CEO of Medically Home.
“It’s a lot of work to put the hospital home program in place. We typically see between four and six months of work ahead of implementation,” Karjian said. “And then within that four- to six-month period, one of the steps that you have to check off is the waiver itself. So we have some customers that like to [get started on that early].”
Boston-based Medically Home is a hospital-at-home enabler. The organization helps its partners coordinate in-home clinician visits and overcome logistical hurdles such as necessary technology, equipment, medication and other supplies.
In May, Kaiser Permanente and the Mayo Clinic invested $100 million in Medically Home. Those organizations – among many others – have also started the “Advanced Care at Home Coalition,” which has a goal of vying for favorable legislation in Washington, D.C., for hospital-at-home programs moving forward.
“This coalition has some proposed legislation that is being worked on that actually has bipartisan support,” Karjian said. “We are hopeful that gets traction. But big picture, we don’t think that health systems would be making the types of investments in this care if they didn’t expect that it would be supported after the PHE.”
Too late to turn back
UMass Memorial may have fewer than 10 patients on its census now, but Eric Dickson, its president and CEO, told HHCN in June that he wanted the program to be 10 times that size by the end of 2022.
“I think that is still the goal,” Michaleidis said. “And we want to be able to expand our home geographies and be able to go to a broader set of zip codes. We don’t want to have to say, ‘Oh, you’re too far away from the medical center for us to be able to get there.’”
The health system has already expanded in the last two weeks into two new towns in Massachusetts.
There’s no turning back now, whether it’s for UMass Memorial or the hundreds of other systems that have committed serious time and resources to what is technically a temporary waiver. In fact, many health systems have even begun programs with partners like Medically Home to run hospital-at-home programs outside the waiver through other payment mechanisms.
About 20% of hospital beds in the country are now under a system that is approved for hospital at home, according to Medically Home. If you exclude smaller, critical-access hospitals, that number increases to 30%.
“So that level of penetration of this idea only comes because of the expectation and hope that CMS will continue this,” Karjian said. “We know from our conversations with our customers, CMS and [Center for Medicare & Medicaid Innovation], that there’s a lot of emphasis on – and support for – this model.”
In order to continue, however, more specific metrics need to be established, advocates believe. For one, CMS fee-for-service reimbursement mechanisms need to be replaced by bundled payment or capitated arrangements, according to a report published in the American Journal of Managed Care (AJMC).
“Patients and doctors have grown comfortable with telemedicine and have a newfound appreciation for the benefits of home health care services,” the report’s authors wrote. “With careful patient selection, the hospital-at-home model has the potential to significantly benefit a subset of patients. To create sustainable reimbursement mechanisms for hospital-at-home programs, we first need a better definition of the value provided by this model of care.”
According to the authors of the report, quality reporting should include both inpatient-specific and home health care-specific metrics, equity-focused process metrics and risk-adjusted outcome metrics and validated disease-specific tools.
“I cannot express how critically important it is to extend the waiver via legislative processes past the end of the federal PHE,” Michaleidis said. “Because if that doesn’t happen, all of these vulnerable patient populations with Medicaid, with traditional Medicare will lose access to this incredibly safe and effective care model in the home.”
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