Hospital care at home faces possible sunset

A pandemic-driven workaround that delivers hospital-level care in patients' homes could become a bargaining chip as Congress hashes out a year-end spending deal.

Why it matters: The Acute Hospital Care at Home program is held up in some health circles as a viable model for treating frail Medicare patients while relieving overcrowding in inpatient settings.

• But it's one of a long list of COVID-era flexibilities that could sunset at the end of the public health emergency without congressional action.

How it works: Since the fall of 2020, hospitals can apply for waivers and, if approved, be reimbursed the same amount by Medicare to provide 24/7 services in patients' homes.

• 257 hospitals in 37 states are currently using waivers to provide acute hospital-level care, working with companies like Medically Home and DispatchHealth.
• But while the public health emergency runs through at least April, advocates for the model say the push for more decentralized care hinges on Medicare's continued involvement — and on lawmakers extending the program and providing some certainty beyond the crisis.
• "Once the PHE ends, if there isn't something like this, they're going to have to stop offering this care for Medicare and Medicaid fee-for-service," said Rami Karjian, CEO of Medically Home, which is backed by health systems like Mayo Clinic and Kaiser Permanente.

Go deeper: The leading vehicle is a plan from Sens. Tim Scott (R-S.C.) and Tom Carper (D-Del.) that would extend waivers for Acute Hospital Care at Home for at least two years beyond the expiration of the emergency.

• "This looks to me like something that's pretty clear cut, takes pressure off, adds value, saves a little money and deals with the amazing stress on providers and patients," Rep. Earl Blumenauer (D-Ore.), who's co-sponsored a House companion bill, told Axios.

Yes, but: The extension is one of numerous end-of-year priorities lawmakers will have to sort through. Congressional scorekeepers haven't put a price tag on the bill. Axios' Maya Goldman previously reported it would not add any new federal spending, which could boost support for the extension.

• Offering high-level care outside of hospitals can be a costly proposition: Kaiser Permanente has hired separate care teams and invested in technology like iPads and at-home medical equipment to start the programs.
• Some providers also remain reluctant to discharge patients to home settings or adapt to treating patients outside of institutional settings, per HealthcareDive.
• Hospital workers may have to use telemedicine more and trust patients and families to be honest about symptoms and sticking to care plans, Intermountain Health hospitalist Nathan Starr told the publication.

The big picture: Hospital at home gained traction quickly early in the pandemic as hospitals crushed by COVID surges looked to alternative placements for inpatients, including field hospitals.

• Now, the industry is facing labor shortages and is increasingly hard-pressed to discharge patients to nursing homes and other institutional settings. Advocates of the model say that hospital care at home can alleviate some of the pressure and capacity issues.
• "We're able to provide care in the home at a much lower price point and better experience instead of them staying in the hospital setting or [skilled nursing facility]," Dan Trigub, CEO of MedArrive, which offers post-hospitalization follow-up in the home, told Axios.

How it works: In Kaiser Permanente's Oregon and Northern California markets, some patients with infections like pneumonia or who are recovering from heart failure or other complications that landed them in the emergency department are eligible for the hospital-at-home program.

• The average length of stay in Kaiser Permanente's hospital-at-home care program is four to five days.
• In some cases, patients can be transferred directly from the emergency department, with a clinician and patient approval. A virtual care team connects with the patient via iPad at least twice a day, as well as an in-person care team that checks in.
• So far, it appears to be reducing hospital readmission rates: Kaiser's 30-day readmission rate for patients in the program is 8%, compared to the national hospital average 30-day readmission rate of 13%.
• The model lowers the risk of readmission for patients with chronic diseases and a similar mortality risk to patients treated in hospitals, a 2021 JAMA analysis of nine studies on hospital-at-home programs found.
• Additionally, the JAMA analysis found that the home care model is better for patients' mental health, lowering depression and anxiety.

The bottom line: Offering high-level services outside the hospital can be complicated and capital-intensive.

• "I worked at Uber and Lyft. It’s hard enough getting a Millennial to a bar on a Friday night and actually making money in doing it. It’s another thing to offer on-demand concierge medicine," Trigub said.
• Stephen Parodi, associate executive director of the Permanente Medical Group, said an extension of the program could give providers time to study the costs of scaling up more decentralized care.

Editor’s note: This story has been corrected to reflect the co-sponsor of the legislation to extend hospital-at-home flexibilities is Sen. Tim Scott (R-S.C.), not Rick Scott.