The hospital-at-home movement has been a striking trend in the home-based care space over the last few years, but it hasn’t been driven by home-based care providers.
Health systems and hospitals have been the ones benefiting from increased access to patients’ homes, sometimes partnering with home health or home care providers — and sometimes not.
There are those who want to change that, however, believing that centering hospital-at-home models around home-based care providers is the best way forward. A bottom-up approach – where the model would start with community-based organizations, instead of health systems – would be more practical from a patient and reimbursement perspective, they believe.
“First and foremost, [the bottom-up approach] expands who can actually provide this type of care, because the waiver program is only for hospital systems, and there is some momentum around trying to give this allowance to large physician groups as well,” Dr. Anna Loengard, the CMO of AccentCare, told Home Health Care News. “But right now, it’s a fairly narrow lens on who’s able to apply for a waiver. I think that you could argue that many hospitals really don’t understand the space of the home. That’s not really their bread and butter. Whereas community-based providers, we do it every day.”
Dallas-based AccentCare is one of the largest providers of home health care in the U.S. The company also provides personal care and hospice services, with over 270 locations across 32 states.
The company began working on hospital-at-home initiatives as far back as six years ago with certain health systems.
Under the current Acute Hospital at Home waiver program, which was created by the Centers for Medicare & Medicaid Services (CMS) during the public health emergency (PHE) to ease capacity pressures, there have been 107 health systems and 242 hospitals in 36 states approved to deliver this type of care.
Not every approved health system or hospital is utilizing the waiver’s allowances. But many brick-and-mortar institutions are looking to use hospital at home as more than just a solution to a temporary problem.
The Acute Hospital at Home waiver is set to expire at the end of the PHE, which does present a regulatory cliff for providers. The “Hospital Inpatient Services Modernization Act” has been introduced in order to extend the waiver two years past the PHE.
“I think there’s a lot of advantages to expanding who could actually conceive a program and manage it,” Loengard said. “Especially when you model out what this would cost. I do think that, with the Choose Home legislation and the SNF-at-home model, in an ideal world it probably needs to be a ‘home health reimbursement plus.’ But I think that it still ends up being a less expensive model, and provides greater latitude on who can provide that model.”
Broadly, the Choose Home Care Act of 2021 would incentivize home health agencies to provide skilled nursing facility-level care in the home. Essentially, it would add another layer to the current home health benefit.
The bill has been touted by home health providers, especially the large ones, but has hit a snag in Washington, D.C., due to political roadblocks.
Dollars and cents
During AccentCare’s trials with hospital at home, it has been able to save upwards of $5,000 per patient in some cases. Hospitals and health systems have shared some of those savings, while also creating more capacity.
But a bottom-up approach, as opposed to today’s more traditional, top-down approach, would yield even more savings, according to AccentCare’s findings, which were published in HealthAffairs in May.
Specifically, the authors – including Loengard – found that the bottom-up model cost payers $10,500 per episode, while the top-down model costed $17,500 per episode.
“The payment rates for home health services are lower, and even when you layer on the additional services that would be needed for a home health agency to coordinate a home hospitalization — things like meals, a hospital bed, or other equipment — you still don’t reach the larger cost of an acute inpatient DRG payment,” one of the authors wrote. “The cost differential we found between the top-down and bottom-up approaches is driven by core differences in the way payment rates are set for home health versus inpatient services.”
The payment logistics for hospital at home would need to change in order to realize these savings in the first place, though.
A Choose Home bill would need to come to fruition, perhaps with some add-ons, to create that “home health plus” payment mechanism, as Loengard previously noted.
Increasing access to hospital at home
In addition to reimbursement and a greater involvement of home-based providers, a bottom-up approach would also increase patient access, stakeholders believe.
“It’s also about access,” Loengard said. “If a hospital creates a program in a market, competing hospitals are never going to refer into [each other’s] hospital-at-home programs. So it’s sort of a limiter in terms of which patients should have access to it. Whereas if it was created by a community-based organization, there’s a greater likelihood that there could be more than one hospital referring into it. It creates that possibility, which also creates greater access and better coverage for any given community.”
This isn’t an issue solely identified by home-based care providers, either.
While grateful for the Acute Hospital Care at Home waiver at the time, health systems have recognized some of its warts while utilizing the waiver.
“The waiver program – while well intended – is tough,” Christi McCarren, MultiCare’s senior vice president of retail health and community-based care, said last September at the FUTURE conference. “Our advanced care program, [for instance], identifies those patients in the community, whereas theCMS waiver program identifies them in the hospital.”
The Tacoma, Washington-based MultiCare Health System is a nonprofit health care organization.
While hospital-at-home models have been around for decades in the U.S., widespread adoption – even after the Acute Hospital Care at Home waiver – has lagged.
Even if a bottom-up approach becomes more feasible, Loengard believes there’s value in having different sorts of model to increase availability and access.
“There are multiple ways of getting providing greater access,” she said. “And I feel like we’re still a surprisingly nascent in providing this type of care across the country. So I think that it’s probably worth having multiple models that are available.”
Home Health Care News + Hospice News Managing Editor Robert Holly also contributed to this report.
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