Select Key Findings
- In December 2022, Congress approved the extension of the CMS waiver program through December 2024, despite the fact that public health crisis conditions have waned and that no data exist on the relative care quality and costs of in-patient hospital care versus H@H [Hospital at Home] services.
- Under the current CMS program, Acute Hospital Care at Home (AHCaH), hospital physicians must approve patients for at-home care and hospitals must provide the array of lab, equipment, infusion and other services typically found in hospitals; but the program waives critical nursing care and safety standards, including 24/7 care by RNs. Rather hospitals must respond to in-home emergencies within a 30-minute window and may use paramedics rather than RNs for two daily in-person visits.
- H@H depends importantly on telemedicine and remote monitoring to replace in-person care.
- Despite the lower costs and requirements for H@H programs, CMS reimburses hospitals at the same rate that it does for inpatient care, including costly “facilities fees.”
Policy Issues
- As an emergency program, CMS did not develop rules and procedures for H@H programs equal to those that currently cover acute-care hospitals. These include:
- adequate standards, measurement tools, data collection, and monitoring and auditing processes to assess care quality and costs in H@H programs;
- adequate rules for sharing the cost savings and adequate data reporting requirements to assess the real costs of H@H programs compared to hospital-based care.
- The lack of adequate CMS standards, data, and oversight systems for H@H programs provides incentives for financial interests to take advantage of taxpayer subsidies for private gain.
- Research is needed to assess the relative trade-offs of in-patient versus H@H care, including:
- whether in-home care provided by paramedics, as allowed in the CMS H@H program, is equivalent to that provided by RNs, as is required in hospitals;
- whether medical error rates in H@H programs are higher than in hospital-based settings, as some research currently finds;
- whether telemedicine and remote diagnostics and monitoring can effectively substitute for in-person care;
- whether current rules governing legal liability for patient care errors are sufficient when a patient is located at home and the lines between hospital and at-home care are blurred.
- Policies and regulations for H@H programs are needed to address the findings of scientific research. [..]
Debating the Future: Does H@H Save Costs and Improve Patient Care?
“[..] Recent studies of cost savings from H@H programs range from 20 percent (Reese 2021) to 40 percent (Brigham and Women’s Hospital in Boston, Levine et al. 2020). But these findings are not generalizable as they are based entirely on single case studies of highly structured programs involving small samples of very carefully selected patients. For example, the study of Brigham and Women’s program examined 91 adults who were admitted to the hospital’s ED and randomly assigned to the hospital vs home for treatment. [..]
While providing more acute care in patients’ homes has the potential to lower healthcare costs and may help patients recover more quickly, the cost-benefit analysis appears to hinge on billing and reimbursement strategies. As the lead physician for Mayo Clinic’s Advanced Care at Home notes, “There is a cost to bring the technology to a patient’s home, set up transportation and the right staffing model, but there is also huge cost savings due to the fact there is no billion-dollar hospital, laundry, electricity, cleaning costs and other overhead (Kacik 2022).” Whether lower costs will lead to lower prices for patients and payers — Medicare, Medicaid, and private insurers — is an open question. [..]
Beyond the issue of shared savings is the larger question of whether the quality of care in H@H programs is equal to that of inpatient settings. Many doctors have been reluctant to discharge acutely ill patients to be cared for in their homes because they are especially worried about the quality of clinical care provided there (Pifer 2022; Kacik and Devereaux 2022). An early meta-analysis of Hospital at Home programs found positive patient satisfaction and lower mortality and readmission rates (as well as cost savings), but again, the studies were based on small samples of patients in carefully curated programs (Caplan et al 2012). More recent studies have found higher patient satisfaction as well as lower lengths of stay, readmission rates, and visits to the ED. But they are also based on single cases of well-developed and resourced programs by industry leaders, such as Presbyterian in Albuquerque (Klein, Hostetter, and McCarthy 2016) and Mount Sinai in NYC (Federman et al. 2018). These programs have a decade of experience using tightly structured programs with carefully selected patients and physician and nursing oversight. These studies pre-date the CMS program and did not examine the costs of the bundled programs. [..]
Quality experts and nursing organizations cite a lack of data as the reason they are unwilling to declare Hospital at Home a safe alternative to in-hospital care. The Emergency Care Research Institute (ECRI), an independent nonprofit that tracks healthcare safety and quality, cites a lack of peer-reviewed research on Hospital at Home health outcomes for its reluctance to take an official stance on these programs. And limited outcome data have led private insurers generally to be hesitant to reimburse Hospital at Home care (Kacik and Devereaux 2022; Perna 2022). Moreover, advocates rarely mention that clinical outcomes for patients cared for in their homes were not better than for those admitted to the hospital (also no worse as they did not differ), or that pain control was worse for patients receiving care at home. [..]
The effectiveness of telemedicine and remote monitoring as substitutes for in-person care is also an unproven concept. While research shows that the COVID-19 crisis has led patients to become more accepting of telehealth as a substitute for in-person meetings, technology may not be able to replace a person with the training and skills to treat patients requiring acute care. Moreover, after nearly two decades of failures at implementing effective integrated electronic medical records systems, it is not self-evident that hospitals and health IT companies will do better with telemedicine for Hospital at Home.
In sum, research clearly shows that the quality of care depends importantly on the level of skilled healthcare professionals who provide it. Meeting staffing needs, however, is perhaps the most critical need for healthcare providers post-pandemic. While the CMS requirements state that on-site visits may be performed by RNs or paramedics, the difficulty recruiting RNs may lead to a norm in which RNs continue to be employed in hospitals (a CMS requirement), but are replaced by paramedics or EMS employees in at-home programs because they allow this substitution. Moreover, the CMS reimbursement formula that pays H@H services at the hospital inpatient rate may create perverse incentives for hospitals to skimp on labor costs in their H@H programs by utilizing lower-paid labor, such as paramedics or EMS employees rather than RNs.”
Conclusion and Policy Implications
“[..] Beyond a handful of carefully curated case examples, no systematic evidence exists that H@H services to the acutely ill yield better patient care or lower costs compared to the current hospital-based system. No evidence exists that a widespread shift to H@H programs will improve the overall US healthcare system. Moreover, CMS has established no system to adequately collect data and monitor and enforce care quality and patient safety in the home at the level that currently exists for hospital-based settings. This is especially problematic because some emerging research finds home-based patients face higher medication errors, especially infusion errors, which lead to higher hospital readmissions or emergency room visits. [..]
Related to the issue of the de-professionalization of health care is the emotional burden placed on family members — who without the ongoing availability of skilled staff may feel obliged to fill in the gap while worrying about their capabilities to do so. H@H programs are likely to shift the often-hidden labor costs to patients’ families, or patients at home alone with only remote access to help. [..]
The debate over Hospital at Home also needs to be considered in the broader framework of the US healthcare system and its current deficiencies and inequalities. Beyond care quality, patient safety, and the deprofessionalization of health care, is the question of who benefits from the cost savings? CMS has no standards in place to require H@H providers to share the cost savings with payers, patients, or their families. Past experience with providers sharing cost savings is not promising. For example, in the Medicare Advantage program offered by commercial insurers, several recent investigative reports have found that these plans have overcharged taxpayers millions of dollars by aggressively coding patients as sicker than they actually were (Schulte and Hacker 2022). The New York Times found that eight of the 10 largest MA insurers, controlling two-thirds of the market, had overcharged Medicare, according to federal audits (Abelson and Sanger-Katz 2022). And a Senate investigation found that MA plans engaged in widespread deceptive and predatory marketing practices targeted at seniors (U.S. Senate Committee on Finance 2022).”
Full report, E Appelbaum and R Batt, Center for Economic and Policy Research, 2023.1.24