An outcome of the COVID-19 pandemic has been the attractiveness of innovative care alternatives, for patients and providers alike. One model that has become increasingly popular in the United States (and which is already established globally) is the Hospital at Home program, which allows patients who need acute-level care to receive that care in their home.
The benefit for patients is clear: the patient can receive hospital-level care from the comfort of their home, instead of in an impersonal setting where the potential risk of hospital-acquired infection may exist. For providers, the Hospital at Home program offers a chance to relieve the systemic stress on their facilities caused by patient surges or staffing shortages and to meet patient preferences for care setting. The main deterrent for providers implementing the Hospital at Home care model has been reimbursement, for which there is now a short-term opportunity.
In November 2020, the Centers for Medicare and Medicaid Services (CMS) launched the Acute Hospital Care at Home program, which required interested hospitals to apply for a waiver of Hospital Medicare Conditions of Participation mandating 24/7 nursing services to be provided on the hospitals’ premises and requiring the immediate availability of a registered nurse. Participating hospitals in the CMS program were also required to meet certain criteria, such as the requirement that all Acute Hospital Care at Home patients be admitted from either an emergency department or inpatient hospital setting. As of April 12, 2023, 123 systems and 277 hospitals in 37 states are approved for Acute Hospital Care at Home.
While the waivers were originally set to terminate at the end of the COVID-19 Public Health Emergency, bringing with it the end of reimbursement for the program, the omnibus spending bill that became law on December 29, 2022, extended the Acute Hospital Care at Home program through the end of 2024. This extension provides an opportunity for hospitals to build-out their Hospital at Home systems, which must be measured against the risk of the Acute Hospital Care at Home federal funding not being extended past 2024.
As hospitals grapple with the decision of whether to apply for a waiver and launch a Hospital at Home program, there are certain regulatory implications which must be considered:
- At this time, Hospital at Home services are reimbursed through the inpatient prospective payment system, and hospitals currently receive the same inpatient payment they would have received if the care was provided in a traditional inpatient setting. Whether that will be the case moving forward remains to be seen as questions remain as to whether facility overhead expenses should be considered in calculating reimbursement for services provided in the home.
- CMS recognizes that “at home” could include persons residing in assisted living facilities or nursing facilities. Providing Hospital at Home care to persons residing in these settings requires a review of billing practices to ensure that there are no duplicate payments made to assisted living facilities or nursing facilities while the hospital is being paid for inpatient levels of care.
- While Hospital at Home may be covered under Medicare, a review of state Medicaid policies is essential as additional requirements may apply to those programs. For example, in Massachusetts, hospitals are required to submit a copy of the CMS waiver approval to MassHealth and, when billing, there are required codes that must be included in the appropriate field on the claim.