Hospital at home lacks 'standards and accountability,' research professionals warn

Hospital-at-home programs can help ease many pressures on the healthcare industry, such as staffing and inpatient overcrowding. But "too many questions remain unanswered" for CMS to approve them permanently, research professionals argue in a recent article. 

The article was written by Rosemary Batt, PhD, a professor at Ithaca, N.Y.-based Cornell University's School of Industrial and Labor Relations and co-editor-in-chief of Industrial and Labor Relations Review, and Eileen Appelbaum, PhD, co-director of the Center for Economic and Policy Research. It was published to the Gerontological Society of America's Public Policy & Aging Report on May 3. 

"Beyond a handful of pre-pandemic small studies, no systematic evidence exists that the current CMS hospital-at-home programs provide the same level of care that hospitals provide for the acutely ill," Dr. Batt said in a May 9 article in the Cornell Chronicle. "Too many questions remain unanswered, and CMS lacks the necessary reporting and data systems to ensure provider accountability."

In November 2020, CMS sought to decrease COVID-19 pressures on hospitals by issuing an emergency policy that waived certain requirements around 24/7 nursing care for acutely ill patients. Hospitals were reimbursed at the same rate for home programs as for inpatient care, despite footing lower costs, according to the authors. 

In December, CMS extended this policy through 2024, and now two groups are lobbying to make it permanent: the American Hospital Association and home health agencies. 

Many of these home health agencies work with financial actors such as private equity firms, which build lower costs into their models. They replace registered nurses with lower-skilled, lower-paid workers such as paramedics and emergency medical technicians and this step toward "deprofessionalizing" healthcare could be dangerous, Dr. Batt said. And as some duties fall to families, it becomes unclear who bears legal responsibility for medical errors. 

Registered nurses are among the loudest critics of hospital at home, saying the system uses unproven technologies. Additionally, there is not enough research comparing the cost and quality of hospital versus at-home care, they allege. 

With hospitals and private actors reaping financial benefits, the authors fear patients will be negatively affected — whether through surprise medical charges, improper upcoding of patients, deceptive marketing or a general lack of transparency. 

"Who benefits from the cost savings?" Dr. Appelbaum told the Cornell Chronicle. "In the current system, there are too many incentives for hospitals and healthcare companies, as well as opportunistic financial actors such as private equity and venture capital firms, to make money while leaving patients, families and taxpayers to bear the costs."

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