Why An Active Public Health Emergency Is Beginning to Hurt, Not Help, Providers

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The public health emergency (PHE) was once considered an oasis of sorts, both for home health agencies and health systems looking to deliver hospital-level care in the home.

But after being active for two and a half years, the length of it – and the continued, but uncertain, prolonging of it – is causing problems for any operator delivering home-based care.

Home Health Care News wrote about the “rude awakening” that home health providers could be facing when the PHE does eventually end, but just last week, it was extended yet again. And all signs point to it being extended through 2022 into 2023, too.


I talked with Dr. Stephen Parodi of Kaiser Permanente about the extension this week, and what it meant for hospital-at-home programs operating under the PHE-afforded Acute Hospital Care at Home waiver.

He and others have been vying for the “Hospital Inpatient Services Modernization Act,” which would extend the hospital-at-home waiver by two years post-PHE and create more reporting measures and guardrails for programs.

“Where I think there is a potential roadblock here is the PHE and its potential extension,” Parodi told me. “In some ways, the extension of the public health emergency, potentially into 2023, gives us an ongoing extension of being able to work under the existing waiver. But it also continues to create uncertainty over whether we’re going to have continued stability beyond the ending of the public health emergency.”


Parodi is the executive vice president of external affairs, communications and brand at The Permanente Federation, as well as the associate executive director of The Permanente Medical Group.

In this week’s exclusive, members-only HHCN+ Update, I examine why the PHE has placed many home-focused health care providers in purgatory.

A long-lasting but temporary change

The public health emergency was first declared in March of 2020, retroactive to January of 2020. Throughout that time – from then to now – it has been a useful vehicle to remove some of the red tape that home-based care organizations faced.

At the same time, it has created a whole new sect of home-based care players. Hospital-at-home models, while popular in other countries, had failed to catch on in the U.S. That’s until the Acute Hospital at Home waiver was created, which allowed health systems to deliver hospital-level care in the home and be appropriately reimbursed.

Since then, there have been numerous success stories and growing censuses. Traditional home care providers have even chipped in to make these programs work, given their expertise in the home setting.

As of June 28, there were 107 health systems and 242 hospitals in 36 states approved to participate in the waiver program. But many of those that are approved have yet to begin building out their programs, hindering innovation and patient choice.

The reason is simple: the pending status of the PHE.

“We’ve got more than 240 programs in 36 states that have been approved to participate in this program, but some of them are waiting on the sidelines before they jump in,” Parodi said. “Because they want to know that there’s some certainty that in the next couple of years, they’re going to have that time to ramp and build those programs up.”

On Kaiser Permanente’s end, its hospital-at-home program has steadily expanded. It has cared for over 1,600 patients in its program since the onset of the pandemic, and it has aggressive plans for future growth, even by 2023.

The PHE still being in place certainly still makes sense. While vaccines have been available to most of the country for well over a year now, COVID-19 cases are still going through ebbs and flows. As we sit here Thursday, the daily cases average in the U.S. is close to 130,000, an 18% increase over the last two weeks, according to the New York Times.

But arguing over whether there is an ongoing public health emergency is missing the forest for the trees.

All of the flexibilities that have been granted to operators – many of which should have probably been granted in the first place – have become commonplace.

There are home health workers who have never experienced a working world where a non-physician, for instance, couldn’t certify home health care.

“They came into [home health] at the same time as the waiver,” Cindy Krafft, the co-owner and co-founder of the consulting firm Kornetti & Krafft Health Care Solutions, recently told HHCN. “What they think is routine — being a PT and doing the admission or being a nurse and not needing to always do it — may be a bit of a rude awakening. It’s normal to them, but this is technically a waiver that is going to go away at some point.”

The PHE has affected the way the entire health care world operates. There are workers becoming attuned to an environment that may not exist in a year, akin to teaching a child cursive writing when they will be typing their assignments on a computer once they graduate elementary school.

In the hospital-at-home space, workers are also reporting increased satisfaction with their work when in the home, which could theoretically be yanked from them post-PHE.

At the same time, the PHE has let even the most pro-home-based-care lawmakers take a breather, a breather that can’t be afforded from health systems’ perspective, Parodi said.

“If Congress doesn’t think they need to pass anything because the PHE is going to be extended, the momentum to move this along, unfortunately, is hindered. It’s a concern of mine,” Parodi said. “It’s really important that we impress upon everyone that in order to get these programs off the ground, you need to have the stability of knowing that you’re going to have the regulatory framework to keep them in motion.”

The Hospital Inpatient Services Modernization Act is necessary, Parodi argues, because some of these programs are now as big as regular, brick-and-mortar hospitals that have plenty of guidelines, reporting measures and best practices afforded to them, and required by them.

Hospital-at-home programs still, mostly, do not.

“The CMS framework that’s required in this act is going to be important,” Parodi said.

If legislation is not passed while the PHE hangs in limbo – or because the PHE hangs in limbo – hospital-at-home players and home health agencies will be dealing with this burdensome conundrum for the foreseeable future.

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