Why 'hospital at home' has a 'common agency problem'

"Hospital at home" suffers from what economists call a "common agency problem," three experts on the care model wrote in Health Affairs.

CMS started allowing health systems to apply for waivers to be reimbursed for acute hospital care at home in 2020, greatly expanding the number of hospital-at-home programs.

But for the care model to truly reach its potential, this "common agency problem" must be fixed, according to the May 3 article by Bruce Leff, MD, geriatrician and health services researcher at Baltimore-based Johns Hopkins University School of Medicine, David Levine, MD, clinical director of research and development at Boston-based Mass General Brigham Healthcare at Home, and Albert Siu, MD, geriatrician and health services researcher at New York City-based Icahn School of Medicine at Mount Sinai.

This obstacle arises when "multiple payers contract with a shared or common agent — the hospital in the case of HaH — that wishes to be paid for all patients eligible for a service," the researchers wrote. Resolving this will require the CMS waiver to be made permanent — it currently expires at the end of 2024 — and for all states and their Medicaid programs to get on board with "hospital at home." This will "incentivize other payers to overcome the inertia to enter the HaH market, creating a wide-ranging multipayer environment for HaH," the authors wrote.

"Over decades, researchers have developed and tested multiple home-based care delivery models that can now be brought together into a distributed, decentralized healthcare system that puts the patient at the center of care at home, where they have more agency and power to affect their care," Drs. Leff, Levine and Siu wrote. "HaH is the keystone of this future home-based care ecosystem. It's time to claim the future."

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