Hospital-at-Home Provision Included in Funding Bill Passed by House

The stopgap funding bill passed Tuesday by the House included a provision to extend the CMS “Hospital-at-Home” (H@H) waiver program.

The program, which currently expires on March 31, allows hospitals to provide hospital-level care to certain patients in their homes, even though doing so would normally violate a condition of participation in Medicare and Medicaid requiring 24/7 availability of nursing care. Hospitals participating in the program get paid the same amount for H@H patients as they would if the patient were actually in an inpatient hospital bed. The provision in the House budget bill — which still needs Senate approval — would extend the program through Sept. 30 of this year.

The program, which is also called the Acute Hospital Care at Home program, started in November 2020 during the height of the COVID-19 pandemic. Congress has extended the H@H waivers twice, first in 2022 for 2 years and then again at the end of 2024 for 90 days, according to a fact sheet from the American Hospital Association (AHA). Both extensions received no score from the Congressional Budget Office, meaning they were considered budget-neutral. As of November 2024, 378 hospitals, across 140 systems and 39 states, have been approved to provide H@H services to patients, according to the AHA.

Hospital Officials Like the Program

The program has worked well for Mass General Brigham in Boston, which has been using it since 2017, according to Stephen Dorner, MD, MPH, chief clinical officer of the hospital’s H@H program. “We’ve had 5,800 [H@H] patients come through since 2022, which is 25,000 bed days,” he said in a phone interview, noting that it’s used only for patients with certain conditions — such as pneumonia or heart failure — that can be managed at home with remote monitoring and visits by health professionals.

“We’re in the homes a minimum of two times a day but often more than that,” Dorner explained. “There’s a federal requirement that you have to be able to reach patients within 30 minutes.” Because the program operates in five different hospitals — with three ambulance depots — “that enables us to support patients in 72 towns around greater Boston, which is about 80% of the patients served by our hospitals.”

Published research shows that patients who receive hospital care at home “[do better] when compared with brick-and-mortar hospitals,” he said. “There are lower rates of complications, lower rates of mortality, and lower rates of readmission. Patients are up and ambulatory more than when they’re in the brick-and-mortar hospital because they’re actually moving around their own home instead of being confined to a hospital room … [It also brings] needed capacity relief to the brick-and-mortar hospitals with the capacity crisis that hospitals face.”

But doesn’t the H@H program take hospital staff away from providing on-site care? Not really, Dorner said. “One of the key provisions of the federal waiver is that paramedics who have additional training as mobile integrated health paramedics or community paramedics can deliver care to patients alongside nurses. So that’s great, because every patient still gets a nurse, and a nurse is still advancing their care plan, but for more technical visits, where it’s a blood draw or … an infusion of a medication, that can be performed by a paramedic. Then that permits a nurse to be able to support a more patient education-heavy visit, for example, or a more complex visit for wound care.”

Not a New Idea

Dorner added that “by and large, these programs are functioning very much like startups, trying to figure out and test what this care model really needs to look like at scale. Most home hospitals are operating a handful of beds — maybe a dozen or two beds at a time — whereas, [we have] a much larger operation, and so the imperative of us getting an extension for this is less about the financials, and it’s more about just having the regulatory framework to permit us to continue testing this care model and honing it.”

But Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform in Pittsburgh, said that although hospital-at-home is a good idea, the waiver program isn’t the best way to implement it. “There should be a [permanent] hospital-at-home payment program,” he said in a phone interview. “The problem is, there isn’t anything specifically designed for that.”

And that’s not for lack of trying. Back in 2017-2018, CMS’s Physician-focused Payment Model Technical Advisory Committee (PTAC) — which was formed to consider various value-based payment models for possible adoption — recommended two hospital-at-home models, “but CMS refused to implement them,” Miller said. “Then all of a sudden,” after the pandemic hit, “CMS created this waiver that said you can do hospital-at-home during the pandemic. That enabled hospitals to do what they’d proposed to do, but it wasn’t designed to [permanently] support it.”

Problematic Payment Structure

One problem with the waiver program, Miller said, is that there is no effort to determine whether hospitals are being paid accurately under the program. “In some cases, [H@H] may be more expensive” than what the hospital is reimbursed, “and in some cases less.”

Another issue is that the group of patients who can really benefit from H@H is actually rather small, said Miller. “If you think about it, there are not that many patients who can be taken care of adequately at home without a nurse right down the hall. But there are subsets of patients who can be taken care of at home without being in the hospital because they don’t necessarily need the continuous kind of monitoring they need in the hospital, but they need something more than they could ordinarily get at home.”

Although the waiver program enables that kind of service, the concern is that because the waiver allows the hospital to be paid inpatient rates even for patients who need less than inpatient-level care, “the hospital could have a perverse incentive to send more patients home than should be at home,” he said, noting that the advantage of the models recommended by PTAC was that they set forth criteria for when to consider H@H for a patient, and they varied the payment levels depending on what level of care was needed.

All that being said, the waiver program should be extended because without it there would be no program at all, Miller added. “But you can’t just keep extending the waiver … They should extend the waiver for a period of time — a year or 2 — but during that time there should be a requirement for CMS to create a hospital-at-home program that is designed to pay appropriately for hospital-at-home care for patients who need it.”

Correction: This story was updated to reflect that the House bill would extend the waiver program until September 2025.

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