Hospital-at-home programs in limbo with waiver uncertainty

Modern Healthcare – Wednesday, January 8, 2025
By Diane Eastabrook

Uncertainty over the future of Medicare’s hospital-at-home waiver is hampering some health systems’ plans to launch or expand those programs.

A waiver that reimburses health systems for hospital-level care at home was extended through March 31 under a short-term spending bill President Joe Biden signed last month. That is a drastic reduction from the five-year extension included in an earlier spending deal that was scrapped after President-elect Donald Trump opposed it. Congress could extend the waiver for five years or continue it for a shorter period of time in the next spending bill.

Related: Why home is becoming the future for hospitals

The Centers for Medicare and Medicaid Services has approved nearly 380 hospitals across 39 states to provide acute-level care at home. CMS launched the Acute Hospital Care at Home waiver in November 2020 to free up beds during the COVID-19 pandemic.

With no guarantee that Congress will approve a five-year waiver extension that health systems want, some providers are tabling new hospital-at-home programs or rethinking expansions of existing ones.

Another short-term extension would not give health systems the time they need to launch and scale hospital-at-home programs, said Jennifer Holloman, senior associate director of policy for the American Hospital Association.

“The investment required to stand up hospital-at-home programs doesn’t happen overnight,” Holloman explained. “Contracts need to be executed for remote patient monitoring equipment, meal delivery services and staffing. Those things can take beyond a year to deploy.”

It took even longer for Altamonte Springs, Florida-based AdventHealth to launch its first hospital-at-home program. Earlier this week, the healthcare system began offering patients home-based acute care at a hospital in Winter Park, Florida, more than 14 months after receiving a Medicare waiver.

The uncertainty is throwing a wrench into a pilot program digital healthcare company Vivalink launched in October for hospital-at-home startups, said CEO Jiang Li. The Campbell, California-based company is letting nonprofit health systems interested in providing hospital-level care at home test remote patient monitoring equipment at no cost. In an email, Li said three health systems signed up to pilot the equipment, but six others are waiting to see what happens with the waiver before committing to do so.

There are also concerns that a murky path forward for hospital-at-home at the federal level will discourage some states from approving programs.

California stopped licensing hospital-at-home in 2023, forcing the University of California San Francisco Health System to scrap plans to deliver acute care to patients where they live, said medical director Dr. Timothy Judson. He fears Congress vacillating over the Medicare waiver will not bode well for hospital-at-home in his state.

“I worry that uncertainty at the federal level will decrease the likelihood of California acting to create a path for hospital-at-home locally,” Judson said.

Franciscan Health in Crown Point, Indiana, is delaying the expansion of a program that delivers home-based hospital care until it has clarity on federal and state regulations, a spokesperson said in an email.

Still, the AHA is hopeful the new Congress and the Trump administration will back a five-year Medicare waiver extension, said Holloman. The first Trump administration started the Acute Hospital Care at Home program and it has garnered bipartisan support from Congress. Holloman said the program does not increase government costs since Medicare reimburses home-based hospital care at the same rate as facility-based care.

That optimism is encouraging some health systems to press forward.

Technology company Medically Home, which helps health systems offer home-based hospital care, has a backlog of clients still planning to launch programs, CEO Graham Barnes said in an email.

Boston’s Mass General Brigham is also on track to shift 10% of its inpatient care to its home hospital program over the next few years, said Heather O’Sullivan, president and chief operating officer of Mass General Brigham Healthcare at Home, in an email.

Edison, New Jersey-based Hackensack Meridian Health still plans to apply for additional CMS waivers to expand its hospital-at-home program to five hospitals from three, said spokesperson Jessica Nussman. However, Nussman said the health system needs Congress to continue the waiver for five years to assure the program’s future.

“A long-term extension is needed so Hackensack Meridian Health can continue to invest in this vital program and offer stability to our patients,” Nussman said in an email.

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