Opinion | Congress should reauthorize Hospital-at-Home

An analysis by the US Centers for Medicare and Medicaid Services found Hospital-at-Home patients had lower mortality rates than their inpatient counterparts, lower rates of hospital-acquired infections, and were more satisfied with their care. Hospital readmission rates were higher for patients with certain diagnoses (generally more complex conditions) but lower for others.

A study by Mass General Brigham researcher David Levine found at-home patients were less sedentary than hospitalized patients. While at-home patients had fewer lab orders, imaging studies, and consultations, only 7 percent were readmitted to a hospital within 30 days compared to 23 percent of comparable inpatient patients.

The Congressional Budget Office scored the Hospital-at-Home Program as budget-neutral.

But these programs are at risk if Congress doesn’t act.

That’s because the at-home experiment was only possible because in 2020, during the COVID-19 pandemic, the Centers for Medicare and Medicaid Services issued a waiver requiring Medicare to reimburse for Hospital-at-Home care at the same rate as inpatient care. The waiver also let states reimburse via Medicaid, and Massachusetts is one of around a dozen states where Medicaid pays the same rate for at-home and inpatient care, according to the American Hospital Association. The waiver was extended in 2022 and 2024.

Federal regulators have approved Hospital-at-Home programs at 400 facilities in 39 states. In Massachusetts, programs are run through Mass General Brigham, UMass Memorial Health, Beth Israel Lahey Health, and Boston Medical Center. According to the Massachusetts Health and Hospital Association, these programs discharged 4,500 patients in 2024.

Now, though, the waiver is set to expire Sept. 30, unless Congress approves a bipartisan bill that would extend it for five years.

Constantinos Michaelidis, medical director of Hospital at Home at UMass Memorial Health, said UMass started the program in August 2021 when patients were waiting hours for a hospital bed. Since then, around 3,600 patients have been cared for at home after presenting at one of three hospitals. According to data provided by UMass Memorial, compared to patients using its brick-and-mortar hospitals, Hospital-at-Home patients had 60 to 70 percent lower mortality, 15 to 30 percent higher patient satisfaction, 5 to 15 percent fewer readmissions, and 80 to 90 percent fewer transfers to skilled nursing facilities after discharge.

Michaelidis said he wants to eventually offer Hospital-at-Home throughout the system, and a five-year extension would provide the financial certainty to expand. “These programs take a lot of money to get off the ground,” Michaelidis said. “We need Congress to make sure if we spend $3 million expanding the program, it won’t go away in two months.”

A similar calculation is underway at Beth Israel Lahey Health, which started offering Hospital-at-Home in August 2023 at Lahey Hospital and Medical Center. The program has grown gradually, as specialists in different fields established protocols for who can be served at home. It now admits around 100 patients a month, and the hospital recently started offering physical therapy virtually to at-home patients.

Sue Stempek, vice president of BILH Hospital at Home, said the system is considering expanding the program to additional hospitals, and a long-term waiver would allow for growth and for research studies to evaluate the model’s effectiveness.

An open question is the cost impact. Today in Massachusetts, some commercial insurers pay inpatient rates; some pay less. Lora Pellegrini, president of the Massachusetts Association of Health Plans, said some insurers balk at paying inpatient rates when home care doesn’t have the same overhead costs.

But hospital officials say start-up costs are hefty for staff, equipment, and technology.

South Shore Health closed its Hospital-at-Home program May 17, after 11 months. South Shore Health vice president and chief medical officer Jason Tracy said participants loved the program. But it took time for patients and clinicians to adjust to the idea, and when serving only five or six patients a day, the program lost millions of dollars. “In this environment, you have to put your resources toward stronger financially performing programs that have greater patient demand,” Tracy said.

There are efficiencies in bigger hospital systems. Mass General Brigham has treated over 7,000 patients since January 2022 in Hospital-at-Home programs run through five hospitals. The health system saved 35,000 “bed days,” a measure of how many days inpatient beds would have been filled by those patients.

Heather O’Sullivan, MGB’s president of Healthcare at Home, said the program has expanded to new patient populations — like those in post-operative recovery — and the federal waiver lets the hospital scale up knowing it can recoup costs. Without the waiver, O’Sullivan worried that all but the largest health systems would be unable to make those investments.

Congress should also ask federal regulators to study the costs associated with Hospital-at-Home, to determine whether insurance should continue to pay the same as for inpatient care or whether home hospital can achieve cost savings.

The need to study costs shouldn’t prevent Congress from reauthorizing the waiver for five years, though. Hospital-at-Home provides the care patients want with improved health outcomes, while preserving beds for patients who need inpatient care. That’s a win-win-win.

Correction: Jason Tracy’s title has been corrected.

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