The Five-Year Roadmap for Hospital at Home

Over the past few months, many conversations have taken place between stakeholders in the hospital-at-home industry and the federal government, all aimed at reaching a conclusion about the future of reimbursement for the program via the Centers for Medicare and Medicaid (CMS).  

One key discussion on the table is whether the Acute Hospital Care at Home Waiver expiring in December should be extended for two years or five. A five-year extension is strongly supported by the Advanced Care at Home Coalition and industry stakeholders, Contessa included. And in September, H.R. 7623, which included a 5-year extension of the AHCAH waiver, was forwarded to the House, as amended, by a unanimous roll call vote of 41-0 at the Energy and Commerce Committee. 

There are several reasons why five years is the optimal extension for advancing the success and scalability of hospital at home, and why it’s critical we look at the big picture as the decision unfolds. 

Why a two-year runway isn’t long enough 

A two-year extension to the waiver would allow current programs to continue their operations under the CMS reimbursement, but beyond that, does it help advance hospital-at-home or encourage new health systems to explore executing the model?  

We know that more than 300 hospitals across the country are building strong programs with positive outcomes, and those health systems will certainly continue to invest in the model of care. This is especially true considering how those health systems have been able to leverage hospital at home to increase their bed capacity with lower overhead.  

However, solidifying a new program — even with help from an organization like Contessa that can facilitate change management and operational strategy — requires time. From the planning stages to stakeholder adoption and a scalable program, a two-year window is easily too small to encourage serious interest from new players. 

A five-year extension builds stakeholder confidence 

Because of this, many health systems are waiting in the wings to see what the extension will look like, because they know that with a two-year extension, they will have only just gotten started before it ends and reimbursement is again in question.  

Taking hospital at home from a concept to seeing the first patient takes about six months in most health systems. Healthcare systems that are interested in doing this must also consider capital costs and the nature of change management realistically. In the year after that first patient, there’s a learning curve. At the 18-month mark, they’re finally starting to scale—in a two-year waiver scenario, that’s only six months away from the possibility of a significant change to reimbursement structure.  

A five-year extension presents hospital-at-home as a realistic option to these health systems that are hungry for options to combat problems like capacity constraints, but also need a clear signal that the model is here for the long term. 

Beyond that, the vendors and infrastructure that supports hospital at home faces a similar challenge: to invest in building new business accounts and expanding services into the unique needs of a hospital-at-home program, these vendors and suppliers need to know it’s sustainable. 

Medicaid expansion needs a signal of confidence 

We’ve covered health systems and vendors, but what about payers? The same challenge applies on the payer side, and we’ve seen that play out with Medicaid expansion of hospital at home. Currently, we have nine state Medicaid programs that honor the waiver, which means there’s 41 sitting on the sidelines.  

A two-year runway may also not signal confidence to state Medicaid legislators, due to how fast their process moves. And where we’ve seen Medicaid coverage launched — for example, in Massachusetts — we’ve seen the number of programs increase exponentially and become available to a large swath of the population.  

Research to continue advancing hospital at home will take time 

Another component of advancing hospital at home isn’t just the longevity of programs, it’s developing a stronger care model via research. Hospital at home is becoming the standard of care for a subset of the patient population, but to improve a care model, you need more data, and to get more data, you need more time.  

So far, we have relatively small sample sizes, and as more health systems participate, we have more of an opportunity to collaborate across a broader patient population to standardize our data collection, show the efficacy of hospital at home, and act meaningfully on the outcomes. 

CBO scores favor five years 

Finally, from the perspective of the Congressional Budget Office, a five-year extension has no additive costs over a two-year extension. This is something that is unique in the healthcare world, where typically there are additional costs to be offset annually. Because hospital at home is using the same DRG payments that were already guaranteed, no additional funds are needed. So, from a CBO standpoint there’s no financial downside to a longer extension. 

A five-year extension is a win for everyone involved 

No matter how long the extension turns out to be, Contessa is well-positioned to continue offering high-quality hospital-at-home care, and will continue to advance the model. The question is not if, but when hospital at home will have a permanent reimbursement model in place. Five years will clearly be the strongest launching point for that future and give more health systems and patients the opportunity to experience what we already know: we’re improving outcomes and healthcare delivery each day with this approach to care.