The coming expiration of CMS’ hospital-at-home waiver is sowing confusion and uncertainty among health system executives who oversee the programs.
Some leaders told Becker’s that if the CMS waiver expires Sept. 30 without an extension, they would have to end their programs and send home-based patients back to the hospital. The care model allows patients to receive hospital-level care via in-home technology and medical equipment and in-person and virtual visits with clinicians.
The House Ways and Means Committee passed a bill Sept. 17 that would extend the waiver for five years, while the Senate rejected a government funding stopgap Sept. 19 that would have prolonged it through November. The most recent CMS waiver renewal happened in March, as part of a six-month government spending package, 16 days before it was set to lapse.
“We are on pins and needles for every one of these government shutdown deadlines,” said Michael Nassif, MD, medical director of Kansas City, Mo.-based Saint Luke’s Hospital In Your Home. “Because literally, at 11:59 p.m., if there’s no agreement, we have plan B to return people to the brick-and-mortar hospital.”
His program, which has an average daily census of about 13 patients, is unique in that it only accepts Medicare (it has yet to reach deals with any private payers), leaving it totally reliant on the CMS waiver. Saint Luke’s already has capacity challenges at its four metro Kansas City hospitals, and has found that its hospital-at-home patients are 10 times less likely to end up in a nursing home or rehab.
“There’s actually tremendous bipartisan support for this,” Dr. Nassif added. “So I have no doubt that it will go on. I just fear there might be a week or two of chaos, which would be a lot more chaos for the United States than just Hospital In Your Home.”
Other health systems would shift their programs to focus on treating post-discharge patients at home.
“The inpatient portion of hospital at home for CMS patients at Mayo Clinic will have to shut down with loss of the waiver,” said Michael Maniaci, MD, chief clinical officer of advanced care at home for the Rochester, Minn.-based health system. “That is a huge loss for our patients.”
Dr. Maniaci, whose program treats an average of 30 to 35 patients a day across Florida, Arizona and Wisconsin, said the care model has been shown to “expand capacity, ease strain on hospitals, and give patients access to safe, high-quality care at home.” He said it’s “not a pilot anymore” but the “future of healthcare.”
Health systems have already invested millions of dollars in building hospital-at-home programs, which require mobile devices, medical equipment and even vehicles for the clinicians who provide twice-daily in-person visits. Worcester, Mass.-based UMass Memorial Health, for instance, spent about $2 million to launch its acute hospital care at home initiative, whose existence is threatened by the CMS waiver deadline.
“Our hospital-at-home program, and others across the country, will be forced to stop admitting new patients and all existing patients will be transferred from their home back to our already capacity-strained safety-net hospitals,” said Constantinos “Taki” Michaelidis, MD, medical director of UMass Memorial Health Hospital at Home, which has an average daily census of 15 to 20 patients. “With a longer, five-year extension of the waivers, programs like ours — which have continued to invest in these programs despite the uncertainty of funding — could serve even more of these vulnerable patients.”
Other health systems have resisted jumping into the care model over the continued Medicare reimbursement uncertainty; Best Buy cited it in its decision to exit the space.
“In order to invest in bringing up a program like this, it’s almost like doing a startup, and there’s a huge investment and cost involved in the very beginning,” said Hemali Sudhalkar, MD, national medical director of strategy for Oakland, Calif.-based Kaiser Permanente’s Care at Home program. “It’s really hard for smaller programs and organizations to do this without knowing that we are going to continue this, without the support of CMS and other government entities.”
Newark, Del.-based ChristianaCare plans to sustain its program, which cares for an average of 12 to 13 patients daily, even if the waiver goes away. The organization is working with the federal and state government — Delaware is one of about a dozen states whose Medicaid programs pay for hospital at home — as well as technology providers and other health systems to explore alternative pathways for reimbursement and regulatory compliance.
“Hospital care at home is not just a temporary solution — it’s a transformative model of care that aligns with our mission to make high-quality healthcare more accessible, equitable and personalized,” said Sarah Schenck, MD, executive director of ChristianaCare’s Center for Virtual Health. “We are committed to continuing this innovative program because it improves outcomes, enhances patient satisfaction, and reduces the burden on traditional hospital infrastructure.”
Somerville, Mass.-based Mass General Brigham, which treats up to 70 hospital-at-home patients at a time, plans to launch an early discharge program if the waiver evaporates. State regulations in Massachusetts require commercial payers to follow CMS standards.
“It requires a tremendous amount of effort to try to prepare to shut down a critical operation that’s supporting inpatient, high-acuity level of care for patients across our enterprise and prepare to put them back into brick-and-mortar hospitals or prepare them for discharge on outpatient frameworks,” said Stephen Dorner, MD, chief clinical and innovation officer of Mass General Brigham Healthcare at Home.
The health system, which already has hundreds of patients boarding in its emergency departments, recently expanded hospital at home to oncology and additional postoperative and cardiac patients.
“We want to continue that forward trend of scale and growth and expanding the bounds of what we can do, but instead we’re focusing on how we would discharge all of our patients and wrap up our hospital-at-home service as it’s currently structured in order to comply with the waivers,” Dr. Dorner said.
He said hospital at home has already proven to lower readmissions, improve patient outcomes and boost patient experience — but the “jury’s still out” on cost. The Hospital Inpatient Services Modernization Act, which includes a five-year CMS waiver extension, would require HHS to study, among other outcomes, whether hospital at home is more cost-effective than inpatient care.
“This is the chance for us to identify if this is truly a solution that we can incorporate alongside all of our traditional frameworks for delivering care so we can meet the rising needs of an aging patient population with more complex medical conditions than at any point in history,” Dr. Dorner said. “We’re not going to be able to exclusively build our way to meet that growing demand.”
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