Urged on by COVID-era successes, hundreds of health systems and hospitals across the country are delivering hospital-level care at home. But questions about cost, complexity, and culture are threatening a promising strategy and its ‘toxic positivity.’ Is it time to abandon ship and return care to the hospital?
DECEMBER 2024
ewicklund@healthleadersmedia.com, Linkedin
The hospital and the home could not be more different, yet a bold strategy is trying to merge the two. It’s a gamble that could reshape healthcare—or collapse under its own complexity.
The Hospital at Home strategy, borne out of the chaos of the COVID-19 pandemic, was meant to alleviate overcrowded hospitals and offer patients a more comfortable setting to heal. But as it expands, cracks are beginning to show in its ambitious foundation.
As of December 2024, 373 hospitals across 139 health systems in 39 states have embraced the CMS’ Acute Hospital Care at Home (AHCAH) model, a program that offers Medicare re-imbursement for delivering hospital-level care to patients at home.
On paper, the model combines the best of in-person and virtual care. In practice, it’s a high-stakes balancing act that some argue is teetering dangerously close to failure.
Supporters hail it as a revolution, pointing to studies showing improved outcomes and cost savings. But critics warn of the risks: patients with serious conditions treated far from the safety net of a fully equipped hospital, escalating costs, and a healthcare system strain-ing to adapt.
20%
A Guidehouse survey of more than 130 CEOs found that hospitals are growing their business lines to provide approximately 20% more services outside of the hospital and/or in the home.
Source: Guidehouse
“It’s hard to capture those services,” says Derek Dudley, MHA, FHFMA, EHRC, CHFP, CPC, CRCR, CPAR, VP of Revenue Cycle Operations at Tidelands Health. “There are a lot of [uncer-tainties around] billing for those services in the home.”
Finding A Balance That Isn't There Yet
To sustain a Hospital at Home program, executives need to identify the right patient and see enough of them to support hospital-level intervention in the home. But what is the “right” patient?
“If you're a super complex patient, it's entirely possible that the best place that for you to receive care is actually a hospital and not at home,” says Sachin Jain, MD, MBA, who oversaw one of the bigger Hospital at Home programs at the CareMore Health System (now Carelon Health) from 2015-2020 before becoming CEO of the SCAN Group and Health Plan.
Jain, who wrote an opinion piece in JACC Journals titled “Curing Ourselves of Toxic Positivity for Hospital-at-Home,” says too many health systems and hospitals launching Hospital-at-Home or similar programs are overlooking the complexity and cost of providing hospital-based care at home, not to mention the impact on patients and family.
Sachin Jain, MD, MBA
CEO, SCAN Group and Health Plan
“Make sure you’re not creating new problems,” he says. “We can't allow ourselves to get overrun by a positive sentiment from a cool sounding idea.”
For starters, healthcare executives need to map out a treatment plan that combines virtual and in-person care, juggling telemedicine and digital health technologies with scheduling and sending care teams to the home. Some health systems contract with home health programs for those visits, while others send their own clinicians or specially trained paramedics used in a mobile integrated health program.
Aside from the challenges of putting the right technology in the home to facilitate acute care, Hospital at Home programs often involve a mix of care teams, putting extra pressure on care coordination and management. Scheduling and handoffs for in-person care teams is difficult, especially if that care team is contracted.
“Hospital at Home companies typically want to get paid just as much as hospitals and hospitals want to be reimbursed just as much as they are for an inpatient admission as they are for a Hospital at Home admission,” says Jain.
“We can't allow ourselves to get overrun by a positive sentiment from a cool sounding idea.”
—Sachin Jain, MD, MBA, CEO of the SCAN Group and Health Plan, on hospital at home programs.
Using different care teams can also the continuum of care and confuse patients and care providers, which in turn could negatively affect clinical outcomes. In contrast, a care team for a hospitalized patient controls that care plan, managing treatments and reducing care gaps.
Patient and caregiver advocates are also expressing their concern about the Hospital at Home strategy, pointing out that it can disrupt the home environment and do more harm than good for both patients and caregivers.
“As we know, when you enter anybody's household, no matter what part of the world you're from, you're in someone else's culture,” says Paurvi Bhatt, president and chief impact officer of the Rosalynn Carter Institute for Caregivers. “The way we organize taking care of each other changes household by household. It's not the same as hospital room by hospital room. There's standardization that needs to happen for clinical outcomes that need to somehow meet with the reality of what might happen at home.”
Jain also thinks payers should step up to the plate.
“We have an opportunity to shape this conversation,” he says. “We may be purchasers of this service and we may be enablers of this service, or we may encourage providers to use these services as part of a risk-based, value-based arrangement that we put in place.”
“I think we do have a role in encouraging these kinds of concepts, and overall, I think we need to experiment more with new models of care,” Jain adds. “But oftentimes, ‘new models of care’ is a euphemism for doing less and getting paid just the same amount. And that’s what I want to make sure we’re defending against on behalf of patients and family members.”
Paurvi Bhatt
President and Chief Impact Officer, Rosalynn Carter Institute for Caregivers
Managing Expectations
Several recent studies on the Hospital at Home concept have returned mixed reviews, including one done by CMS.
In September 2024, the agency released its evaluation of the ACHAH program, fulfilling a requirement that accompanied Congressional action in 2023 to extend the waiver through the end of 2024. The results offered a murky picture of the program, showing some positive clinical outcomes but uncertainty over cost.
In its 79-page report, CMS found that Hospital-at-Home patients had a “slightly longer” length of stay than those treated in a hospital setting, while Medicare spending for services furnished during the 30 days after hospital discharge was lower.
It also found 30-day readmission rates for less complex patients were lower than their inpatient peers, but 30-day readmission rates for more complex patients were significantly higher, while 30-day mortality rates were lower or not significantly different.
“The differences attributable to AHCAH patient selection criteria and clinical complexity, as measured across the two groups, make it difficult to conclude that the AHCAH initiative resulted in lower Medicare spending overall as compared to brick-and-mortar inpatient care,” the report concluded.
In May 2023, Eileen Appelbaum, co-director of Cornell University’s Center for Economic and Policy Research and Rosemary Batt, the Alice Hanson Cook Professor of Women and Work at the Cornell University School of Industrial and Labor Relations, published a study titled The New Hospital-at-Home Movement: Opportunity or Threat to Patient Care in the Gerontological Society of America’s Public Policy & Aging Report. The two authors said that while the strategy holds promise, “actual cost savings and quality remain unknown.”
One concern is that Hospital at Home providers and technology platforms are drawing interest from private equity, hedge funds and venture capital investors, who would seek a financial return by introducing cost-cutting measures like replacing doctors and nurses with lower-skilled and less expensive emergency medical technicians or paramedics.
“Who benefits from the cost savings?” Appelbaum told the Cornell Chronicle in a May 9, 2023 story. “In the current system, there are too many incentives for hospitals and health care companies, as well as opportunistic financial actors such as private equity and venture capital firms, to make money while leaving patients, families and taxpayers to bear the costs.”
“Without adequate safeguards in place, the incentives in the current H@H reimbursement system coupled with the lack of government monitoring and enforcement capabilities create great concern that hospitals, HH agencies, and financial actors such as private equity and venture capital firms will pocket the savings of H@H,” the study concluded. “Patients, families, and taxpayers may bear the costs.”
Also weighing in on the long-term viability of the Hospital-at-Home concept is the Bipartisan Policy Center. The Washington-based think tank published a report in July and hosted a Capitol Hill event on November 14 on the AHCAH model. In both instances the BPC called on CMS to extend its model for five years.
“We need research on [hospital at home] staffing metrics, how patients and caregivers interact with the program, barriers for individuals from diverse populations, and opportunities and risks for modifying the program.”
— Lee Fleisher, MD, a senior advisor to BPC’s Health Program and a senior fellow at the Leonard David Institute of Health Economics at the University of Pennsylvania’s Perelman School of Medicine.
“We need to design a good evaluation that properly asks how much does this cost,” Lee Fleisher, MD, a senior advisor to BPC’s Health Program and a senior fellow at the Leonard David Institute of Health Economics at the University of Pennsylvania’s Perelman School of Medicine, said at the event. “We need research on staffing metrics, how patients and caregivers interact with the program, barriers for individuals from diverse populations, and opportunities and risks for modifying the program.”
In its July report, the BPC said studies on the value of the program have been small in scale, and not enough hospitals are embracing the strategy to get a good, clear picture on whether this can be a sustainable national model.
“Congress needs more clarity about the likely financial effects of the model if it were to move from a model with low uptake, which is the case today, to something that would be implemented on a larger scale,” the report concluded.
Two Steps Forward, One Step Back
To be fair, no one is suggesting scrapping the Hospital at Home concept altogether, and several health systems are finding success with smaller versions of the strategy that focus on RPM or care for patients with lower acuity, such as those with chronic conditions.
Jain says the model could be better suited for the skilled nursing facility, which already deals with complex care patients. A so-called Hospital at SNF program could improve clinical outcomes for patients transferred to an SNF and give SNFs the support and resources they need from hospitals to improve care.
One health system forging ahead with an ambitious strategy is Mass General Brigham, whose Home Hospital program, launched in 2016 as pilot programs at Brigham and Woman’s Hospital and Massachusetts General Hospital before the two merged in 2022, recently reached a capacity milestone of 70 beds and is expanding to serve more patients through more hospitals in the system.
“I think the technology is better, but I think the business models have really lagged and I think what really needs to happen is the legacy healthcare system needs to step up its game.”
—Sachin Jain, MD, MBA, CEO of the SCAN Group and Health Plan, on hospital at home programs.
Caroline Yang, MD, associate clinical director of Mass General Brigham’s Healthcare at Home program, says the program is still in its early stages, and health systems like MGB are constantly finding new use cases for the strategy. Recent ideas include post-operative patients, OB-GYN patients and even homeless patients and veterans.
Those different use cases are important, Yang said, because health systems need to find the right patients, and in enough numbers, to justify the costs of the program.
At a digital health panel discussion during the 2024 CES event in Las Vegas, Jared Conley, MD, PhD, MPH, associate professor of the Healthcare Transformation Lab at Mass General and a medical advisor to the Switzerland-based World Hospital at Home Community, said the future of the Hospital at Home strategy will be tied into how health systems change their fee-for-service mentality to support value-based care.
Conley sees hospital-based care at home as a future standard of care, with the current model being an early step in the right direction. Healthcare leaders need to take the complexity out of the model, using new technology and collaborations to redefine both health and care.
Jain agrees.
“I think the technology is better, but I think the business models have really lagged and I think what really needs to happen is the legacy healthcare system needs to step up its game,” he says.
He also believes the industry needs to have a more balanced conversation about the Hospital at Home strategy.
In fact, both supporters and skeptics agree that the Hospital at Home concept needs more time to prove its value—a difficult proposition at a time when healthcare is struggling with soaring costs and razor-thin margins. Many feel that the CMS model is being propped up by Medicare reimbursement, which in turn is supported by waivers that were put in place during the pandemic and have been extended since then.
“There’s no margin in [hospital at home programs] right now. If they can align the incentives, that would work. But it’s very risky.”
—Charlie Brown, Vice President of Revenue Cycle Applications and Reporting for TeamHealth
Those waivers were due to expire at the end of 2025, and with CMS reluctant to continue them any further, industry groups have lobbied Congress to take action. The end of those waivers may prompt several health systems to rethink or even end their programs, while others say they’ll continue regardless.
Yang, at Mass General Brigham, says another extension would give advocates more time to collect the data they need to prove value. Jain, meanwhile, says the industry needs to sit down and have a serious discussion about whether this is a good idea.
“There are unintended consequences to almost every new model of care,” Jain says. “And I think the answer isn’t to stop implementing that new model of care, but it is to have a reasonable conversation about the upside and the downside.
Eric Wickland, Associate Content Manager, Innovation and Technology, HealthLeaders