‘Time To Claim The Future’: The Hospital-At-Home Model’s Chance To Decentralize US Health Care

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Hospital-at-home care has a chance to become a mainstay in the larger home-based care ecosystem. As its stakeholders aim to get it there, there are a few factors that need to be considered.

Firstly, without payment, there is no hospital-at-home model. Early pioneers of the model in the U.S. know that all too well.

But Medicare providing adequate payment for hospital-at-home care during the public health emergency (PHE) was a major first step to get other payers to follow. The Centers for Medicare & Medicaid Services’ (CMS) Acute Hospital Care at Home waiver has already been extended through 2024 – it was initially supposed to expire at the end of the PHE – and now is up for another extension.

Earlier this month, Sens. Tom Carper (D-Del.) and Tim Scott (R-S.C.) introduced a bill that would push back the expiration date of the waiver program by five years. An extension bill was also introduced in the House.

That would make for an obvious tailwind for hospital-at-home stakeholders. It not only would keep the payment valve open for current hospital-at-home programs, but also give health systems interested in the model the assurance that investment will be worth their time.

Additionally, earlier this year, Sens. Marco Rubio (R-Fla.) and Tom Carper (D-Del.) introduced the At Home Observation and Medical Evaluation (HOME) Services Act, which would allow providers to admit patients into hospital at home prior to being admitted in the brick-and-mortar hospital.

The Acute Hospital Care at Home waiver taking on a wider scope, more payers following Medicare’s lead and more home-based care providers becoming involved isn’t just good news for the hospital-at-home model, though.

It pushes forward the idea that the home can eventually be the epicenter of health care in the U.S., which is an idea that many home-based care stakeholders are behind, but also a major departure from the current system.

“One may ask why a five year extension, as opposed to something made permanent,” Medically Home CEO Rami Karjian recently told me. “We think Medicare wants to go the bundled route for making this permanent. We think they have this vision, like with BPCI-A, acute and post-acute care integrated and paid for together. That’s where we think this is ultimately going to go.”

This week’s exclusive, members-only HHCN+ Update takes stock of where hospital at home is at right now, where it’s going and how the model could end up uplifting home-based care overall.

Driving HaH forward

Medically Home – one of the largest hospital-at-home enablers in the country – is on the frontlines of the movement.

There’s one stark difference between health system adoption now, and hospital adoption two or three years ago, according to Karjian.

And that’s timeliness. For instance, the company recently launched a program with the New Jersey-based Hackensack Meridian Health. Within three weeks, it had the equivalent of a 10-bed hospital census within patients’ homes.

“That would have been unheard of two years ago. There were systems that would struggle to get 10 patients in a year or two,” Karjian said. “And that’s a reflection of the commitment that health systems are putting into this. They’re viewing it as a fully integrated part of their capacity operations strategy.”

Karjian noted that Medically Home’s systems have improved significantly over the last few years, which also aids its health system partners. The Boston-based company is backed by the likes of the Mayo Clinic and Kaiser Permanente, and it has relationships with health systems across the country.

In the last two months alone, the company has launched with four new health systems, three of which are in new geographies.

For context, there are currently 330 hospitals and 136 health systems approved for CMS’ waiver program across 37 states.

Not only are hospital-at-home programs better at getting up and rolling in this day and age, but they are also finding ways to care for more complex and socioeconomically challenged populations.

Karjian also provided an example there, with Boston Medical Center, who is treating substance abuse patients and end-stage renal disease patients on hemodialysis – two groups of patients that generally haven’t qualified for hospital at home.

“That whole idea of social determinants of health that so affect this population, and how hospital at home can address that, that’s what we see here with BMC,” Karjian said. “BMC is going to generate a lot of learnings there, and we launched with them about four or five weeks ago.”

That population may be hard to reach just under a Medicare payment system, however. That’s one of the reasons why some have argued that Medicaid is the perfect pathway to scale hospital at home throughout the country.

Right now, there is what the hospital-at-home expert Dr. Bruce Leff – a professor of medicine and director of the center for transformative geriatric research at Johns Hopkins University School of Medicine – calls a “common agency” problem.

“Importantly, the waiver demonstrated to the many thousands of private payers that a leading payer, Medicare, believed that hospital at home is a credible care model, making it easier for them to innovate and follow CMS’s lead,” Leff recently noted in Health Affairs. “Absent established payment, payment needs to be negotiated with each payer, one at a time, making it difficult to achieve necessary culture change and economies of scale.”

In other words, hospital at home has plenty of potential, but there needs to be a more structured payment system – across payers – for it to continue proliferating.

Additionally, the model puts an undue amount of stress on family caregivers in certain instances.

An obvious fix to that would be involving already experienced home-based care providers. A good example of that is Medically Home’s relationship with the home care provider BrightStar Care.

“This movement of getting more of that acute care into the community is going to take community resources supporting and driving it,” Karjian said. “BrightStar is a really good example – among many – of how to give additional tools and capabilities to clinicians caring for patients in the home, at a higher acuity level. … That’s going to be a long-term return for patients, for clinicians and also for [home care providers].”

If home-based care providers become more involved, the hospital-at-home model has the chance to raise all boats in the space, over the next five years and beyond. 

“Over decades, researchers have developed and tested multiple home-based care delivery models that can now be brought together into a distributed, decentralized health care system that puts the patient at the center of care at home, where they have more agency and power to affect their care,” Leff and his co-authors continued. “Hospital at home is the keystone of this future home-based care ecosystem. It’s time to claim the future.”


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