‘The Waiver Program Is Tough’: Issues with the CMS Hospital-at-Home Program

The proliferation of hospital-at-home models has been one of the major home-based care trends during the COVID-19 crisis, and players on all sides are bullish that that trend will continue after the pandemic subsides.

The U.S. Centers for Medicare & Medicaid Services’ (CMS) “Acute Hospital Care At Home” waiver program has allowed more health systems and home-based care agencies to get involved. But there are participants that believe the waiver program – as it is currently constructed – does not represent the best way forward for the concept.

The Tacoma, Washington-based MultiCare Health System, for instance, has two different hospital-at-home models. One model is through the waiver program, and one is through its own partnership with the in-home medical care provider DispatchHealth.

The types of patients in those two programs are the same, but the way it identifies them is different. One of those ways works, and one doesn’t, Christi McCarren, MultiCare’s senior vice president of retail health and community-based care, said recently during the Home Health Care News FUTURE conference.

“The waiver program – while well intended – is tough,” McCarren said.

MultiCare is a not-for-profit health care organization that operates seven hospitals across Washington state.

There are currently 77 health systems and 177 hospitals in 33 states approved for Acute Hospital Care at Home, according to CMS.

In the waiver program, patients land in the ER, then they have to meet the criteria for admission and conditions of participation. If all goes right, they’re able to be sent home.

However, through its partnership with DispatchHealth – announced at the end of 2020 – MultiCare is able to identify hospital-at-home patients before they come into the hospital, in the community.

On its end, the Denver-based DispatchHealth partners with health systems like MultiCare and payers to offer an array of services within the home. Its care teams and mobile units are available every day of the week and help address the needs of patients in order to reduce hospital admissions and other adverse health events.

“Our advanced care program identifies those patients in the community, and we identify them through our care services, our DispatchHealth cars that are in a market, a payer, or maybe a family practice doctor that is trying to keep a patient out of the hospital,” McCarren said. “So it’s community identification versus the CMS waiver program, which identifies them in the hospital.”

The perception of home-level care being less effective than hospital-level care is what makes the waiver’s way of doing things tough.

“[For instance], if you’ve spent hours with sick, ailing parents, and you finally get them into the ER, and some nice person comes to you and says, ‘We would like to send you home,’ are you going to say yes?” McCarren said. “You’re dead tired, you’re not comfortable sending them home, and grandma herself says, ‘What do you mean, I can’t go to the hospital? Am I not good enough?’ My point here is that we need to get past that perception of this being substandard care, which it isn’t. It’s exactly the same, and probably better.”

The acceptance rate for the two programs that MultiCare operates tells the story. For the CMS program, the rate is at about 25% – “on a good month” – while the advanced care program has an acceptance rate of about 98%, McCarren said.

“[It’s 98%] because it’s identified when a patient’s already at home and they don’t have to move again,” she said. “So what’s flawed about the CMS waiver program is how we identify the patients and actually bring them into the program. You have to get by that patient perception. You are also counting on ER doctors that are busy to identify the patients as they come in the door – is that going to happen at every institution? It doesn’t happen in mine.”

Cost savings and outcomes

Regardless of what the next developments for the “Acute Hospital Care at Home” program are, health systems and providers alike are going to continue investing in the concept.

Where it initially offered a way for crowded hospitals to unclog, the cost savings and improved outcomes are what will keep it popular beyond the public health emergency.

“If you look at the early research, it basically says that If you add a post-acute period in the home, you will end up with significantly improved outcomes,” Dr. Mark Prather, the co-founder and CEO of DispatchHealth, said at FUTURE. “And we’ve seen that ourselves here.”

DispatchHealth’s goal is essentially to bring the ER – which accounts for 85% of admissions – into the home.

That’s feasible thanks to its mobile units, which come equipped with almost all of the equipment that patients would need in the hospital during an admission.

“The other issue with the waiver is the cost of it,” Prather said. “Let’s say I get $10,000 for that [diagnosis-related group]. In the model where Dispatch comes out as an ER, it costs a fraction, more like $50 versus $2,000. So all of a sudden, that DRG payment coming out of the hospital, we’ve got to pay that $2,000 off the top, and now we have $8,000 left for that whole episode, which doesn’t leave a lot of profit at the bottom of that. But if you can send the ER to the home to start the episode, that episode makes money. And we can actually lower the cost of care.”

Additionally, when patients are admitted to the hospital, they spend far more time in bed then they would if they were home, McCarren noted. Their health detoriaties, and then they may end up in a facility-based setting when they ultimately could have avoided that.

“I think it’s more cost effective to start the care in the home,” McCarren said. “And we have strong opinions about how much money you actually get with the CMS waiver program versus advanced care starting in the community.”

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