Since the pandemic in 2020, a growing number of healthcare providers have been working to extend their reach into the home using technology and 3rd-party healthcare services. They are part of the ongoing resurgence of “hospital at home” – in which acute care is shifted from hospitals to a more comfortable and lower-cost environment using in-person providers, virtual visits with clinicians and specialists, and remote monitoring. So far, 300+ US hospitals around the country are treating patients at home instead of in hospital settings.

During the pandemic, the Centers for Medicare & Medicaid Services (CMS) began allowing hospitals to care for Medicare fee-for-service patients and Medicaid non-managed care beneficiaries at home, for the same rate as a hospital stay. Because of the public health emergency, the Secretary of Health and Human Services (HHS) was able to waive certain facility standards to launch the “Hospitals Without Walls” initiative in Mar 2020. In Nov 2020, it was expanded into the Acute Hospital Care at Home (AHCAH) initiative under additional waivers of the 24-7 nursing-care requirement. Originally intended to be temporary, the waivers were extended by the Consolidated Appropriations Act (CAA) of 2023 until Dec 2024, after which it will need to be reauthorized by Congress.

To date, there are 337 facilities across 136 systems in 38 states that are approved by CMS for the AHCAH program. The approved health systems include Mass General Brigham, Mayo Clinic, Cleveland Clinic, Cedars-Sinai, Atrium Health, Adventist Health, Intermountain Health, Ascension, Geisinger Health, Kaiser Permanente, Scripps Health, UCSD, UCSF, UCI, UChicago, Northwestern, and Stanford, among others.

Hospital-at-home patients that opt in need to be stable but sick enough to require hospital-level care, and must be reachable by hospitals within 30 min. The model can be used for 60+ different conditions as well as post-surgery recovery. According to a study from 2021-2023 of 11,159 patients, the most common conditions treated under hospital-at-home were serious respiratory infections, heart failure and shock, and severe sepsis or septicemia.

Patients typically receive 1 remote clinician visit and 2 home visits per day from providers (e.g. a paramedic or nurse). These staff can equip homes with remote monitoring (e.g. blood-pressure monitor, pulse oximeter), draw blood, and deliver prescriptions. The services provided can also include infusions, oxygen delivery, lab tests, imaging, transport, food services, physical and speech therapy, durable medical equipment, social work, and care coordination.

There are tradeoffs involved with hospital-at-home care. From a care standpoint, it’s often more comfortable for patients and allows them to move around more. A recent survey found that 84% of patients would be willing to participate in a hospital-at-home program. Another study found that patients receiving care at home experienced fewer depressive symptoms. In-person providers can better understand a patient’s social determinants of health (SDOH) and show patients and caregivers how to perform care at home after discharge. It also frees up hospital beds for critical cases.

The main questions are whether the quality of care is equivalent to hospital care and consistent. The 2021-2023 study saw 38 unexpected deaths or 0.34% of patients in the program – which was considered a low mortality rate. Most of these cases involved a Covid-19 infection with progressive symptoms, and in 35 out of 38 cases, patients had been transferred back to the hospital for at least several days before death.

Overall, hospital-at-home patients saw “minimal complications,” with just 7.2% of patients transferred back to the hospital. For Medicare patients, the median hospital-at-home stay was 5 days – about one day longer than in a hospital setting. Another small randomized study even found lower readmission rates and lower costs for hospital-at-home patients vs. similar-acuity patients in hospitals.

While the AHCAH has some guardrails, providers still have a lot of latitude in how they deliver care, and there aren’t standards for everything. Hospital-at-home patients get fewer lab tests and less radiology, which means less cost and unnecessary testing but could also mean they’re getting worse care. There’s little data on how quickly patients can reach or see medical staff, or on the rates of patient falls and avoidable infections. The lack of standards could become a bigger issue as more players – such as private equity firms – get involved.

The economics of hospital-at-home care are a mixed bag. Because in-person staff needs to be highly trained and travel to patients with everything needed from drugs to lab tests, it can be less efficient in some ways than a hospital setting. On the other hand, hospitals have found it can reduce their cost to deliver care by 25-30%. The economics also improve once patients reach the 30-day mark and Medicare payments become value-based for a 30-day episode.

Mass General Brigham – one of the largest hospital-at-home programs with 250 staff and 70 beds by the end of 2024 – says it’s losing money on the program but freeing up hospital beds for more complex patients. It is targeting 10% of its patients to be cared for under this model, and believes that up to 30-40% of all care in the US could be shifted into the home. McKinsey has estimated that 20% of $1T+ in healthcare spending could be virtually enabled.

Not every hospital is capable of delivering hospital-at-home care. The level of complexity involved has generally filtered for well-resourced, high-volume hospitals in urban areas. As one healthcare exec put it, “Delivering services at home really requires a lot of things to go right and in a particular sequence.” In 2022, just 26 high-volume hospitals accounted for 71% of all hospital-at-home discharges.

Congress appears to be moving towards a temporary extension. Several pieces of bipartisan legislation have been introduced that would extend the AHCAH program for another 5 years, which would allow for further study. The Congressional Budget Office (CBO) has assessed a 1-year extension of the AHCAH program at little to minimal estimated additional costs over the 2023–2032 budget window.

The program could still change in significant ways – some industry watchers believe hospital-at-home patients should not be reimbursed at the same rate as an in-hospital stay (e.g. facility fees). There’s also the case to be made that government payers should receive a share of the cost savings from delivering care at home.

Most private payers and state Medicaid programs still don’t provide coverage for hospital-level care at home. However, a growing number – including Medicare Advantage private plans and 11 state Medicaid programs – are becoming open to it. Already, 32 state Medicaid programs and many commercial payers cover remote patient monitoring (RPM). Single-payer models that are more aligned like the VA and Kaiser have also recognized the value of the hospital-at-home model.

Hospital-at-home is part of a broader shift towards a new model for in-home healthcare that includes other home health care (e.g. skilled nursing), in-home primary care (e.g. house calls), home care, and hospice care, as well as telehealth, online pharmacy, and remote monitoring. An aging population (and declining birth rate) mean emergency rooms are already being overcrowded and it will only get worse. Startups like Medically Home, Honor, Doccla, and Huma are continuing to emerge to serve this market.

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