The Hospital at Home Program Is Having Challenges: What Does this Mean for Hospital Billing Services?

We’ve discussed the Hospital at Home program and its impact on hospital revenue cycle management and home health billing before. But recently, there have been reports of problems with waivers. As you investigate hospital billing services, we want to keep you up to date on what’s going on.

Hospital at Home History
The concept of Hospital at Home became much more popular with the surge of the COVID-19 virus, but its history goes back as far as the 90s, where innovative organizations like Johns Hopkins University was developing its own version. Since then, the Centers for Medicare & Medicaid Services (CMS) has launched its “Acute Hospital Care at Home” program to support hospitals as they address challenges to capacity burdens during the pandemic, helping them deliver acute care safely while promoting physical distancing. The program relies on “waiver” requests. These allow hospitals to waive §482.23(b) and (b)(1) of the Hospital Conditions of Participation – requirements that nursing services be provided 24 hours a day, 7 days a week on premise. They also stipulate immediate availability of an RN for patient care [1].

Earlier in the pandemic, the waiver program was considered an “enormous step forward”, receiving praise from some of the six organizations that were designated as the first participants in the Acute Hospital Care At Home Program. And they had the results to prove it. One of the participants, Brigham Health Home Hospital, found that their program had been effective in lowering the cost of care. This was supported by a randomized controlled trial published in the Annals of Internal Medicine. It found that the adjusted mean cost of home hospital acute care episodes was 38% lower for home patients in comparison to those who received care at a traditional hospital. And the leaders were impressed. David Levine, MD, MPH, MA, medical director of strategy and innovation for Brigham Health Home Hospital, and an assistant professor of medicine at Harvard Medical School praised the program saying “This is the change that we all have been waiting for. It is an enormous step forward for the field because it opens the care pathway to large numbers of patients who have Medicare as their only insurance.” He also praised the way it impacted hospital revenue cycle management, “We consider ourselves to be an innovation shop in home hospital care. So, we are continually adding sensors, new technologies, and different care pathways. Having a stable revenue source for our program allows us to expand in a very stable and guaranteed way.”

The most significant change that David cited was the requirement that a nurse see a person either in person or via video at least once a day [2].

Problems With the Waiver
But with all the excitement and success, problems have arisen, specifically around the waiver itself. One hospital in Tacoma Washington has been a good study in comparison. MultiCare Health System has been running two Hospital at Home models. One is through the CMS waiver program, and the other is through a partnership with an in-home medical provider. Both programs work with the same type of patients. But according to their executives, the waiver program has been a challenge. This challenge might go back to how the waiver program functions.

In MultiCare’s partnership with the home medical provider, they can identify patients eligible for the program before they come to the hospital. But for the waiver program, if a patient comes in through the ER, they’ve met the criteria for admissions and now meet conditions for participation. The acceptance rates for the two programs highlights the issue. For the CMS program, the acceptance rate comes in at 25% when things are good. For their partnership, the acceptance rate is around 98%.

This discrepancy ties to the issue of cost. A MultiCare representative has compared the cost of both programs and relates a hypothetical to explain that costs in the partnership program are a fraction of the CMS path since the home is essentially functioning as a (much less expensive) ER [3].

Understanding the Value of Hospital at Home
But regardless, health systems across the country have been encouraged to invest in the concept. What started as a way to free up hospital resources in the wake of a pandemic has become a way to increase cost savings and improve outcomes, spurring its popularity beyond pandemic applications.

This proliferation has made understanding the value of these programs even more important. In September of 2021 the American Journal of Managed Care discussed a potential framework to define value, one that’s based on cost, quality, and equity [4].

What does all this mean for hospitals interested in home health billing and researching home health billing companies? It means an opportunity. The COVID-10 pandemic has helped get patients more comfortable with home health services through new care models like telemedicine. This means that providers have more opportunity to explore new options for their patients even as they develop sustainable reimbursement. But these providers will be experiencing changes in their hospital revenue cycle management. Many will find that they need support from home health coding companies and home health billing companies. As you explore your options in hospital billing services, we encourage you to contact us for input as you create new programs and partnerships.

[1] U.S. Centers for Medicare & Medicaid Services, “Acute Hospital Care at Home,” 10 January 2022. Available:
[2] C. Cheney, “CMS Home-Based Hospital Care Waiver Called ‘Enormous Step Forward’,” HealthLeaders, 6 January 2021. Available:
[3] A. Donlan, “‘The Waiver Program Is Tough’: Issues with the CMS Hospital-at-Home Program,” Home Health Care News, 11 October 2021. Available:
[4] A. Achanta, D. E. Velasquez and D. C. Grabowski, “Hospital at Home: Paying for What It’s Worth,” The American Journal of Managed Care, vol. 27, no. 9, pp. 369-371, 2021.

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