Hospital-at-home programs lack standards, accountability

Without adequate safeguards, a pandemic policy allowing hospitals to treat acutely ill patients in their homes could enable providers and financial backers to pocket taxpayer subsidies while offering lower-quality care, a Cornell expert warns in new research.

Before agreeing to make “hospital-at-home” programs permanent, Congress and the Centers for Medicare and Medicaid Services (CMS) should conduct research to determine if they save money and deliver treatment on par with inpatient care, said Rosemary Batt ’73, the Alice Hanson Cook Professor of Women and Work in the ILR School.

“Beyond a handful of pre-pandemic small studies, no systematic evidence exists that the current CMS hospital-at-home programs provide the same level of care that hospitals provide for the acutely ill,” Batt said. “Too many questions remain unanswered, and CMS lacks the necessary reporting and data systems to ensure provider accountability.”

Batt is the co-author with Eileen Appelbaum, co-director of the Center for Economic and Policy Research, of “The New Hospital-at-Home Movement: Opportunity or Threat for Patient Care?” published May 3 in Public Policy & Aging Report, a journal of the Gerontological Society of America.

The authors say the decision about whether to make hospital-at-home programs permanent in non-crisis conditions “is an important policy for debate, particularly for older adults who are disproportionately affected.”

The current program emerged as a response to the COVID-19 pandemic overwhelming hospital capacity. In November 2020, CMS issued an emergency policy allowing acutely ill patients to be treated at home with doctors’ approval, waiving certain requirements including around-the-clock nursing care.

The policy reimbursed hospitals at the same rate as inpatient care, including for a “facilities fee” intended to cover hospital maintenance costs, despite far lower costs for in-home care, according to the authors.

By November 2022, CMS had certified 256 hospitals and 114 health systems, but many hospitals hesitated to start programs because of uncertainty about long-term funding. In December 2022, Congress extended the policy through 2024, and many more providers are expected to pursue certification.

Now two coalitions are lobbying to preserve the emergency policy and its funding structure permanently – one led by the American Hospital Association, the other by home health care agencies working with financial actors such as private equity firms.

Advocates say hospital-at-home programs enable patients to receive quality care in the comfort of their homes at lower cost, taking advantage of advances in telemedecine and remote monitoring technologies. Critics – led by the largest union of registered nurses – say those technologies are unproven and cite a lack of research comparing the cost and quality of hospital and at-home care.

Batt and Appelbaum say that while the programs have intuitive appeal and some studies show higher patient satisfaction rates, “actual cost savings and care quality remain unknown.”

A major concern, they say, is the growing interest of private equity, hedge funds and venture capital investors in hospital-at-home providers and the technology platforms their business models rely upon. Financial strategies build in lower costs by replacing registered nurses with lower-skilled and lower-wage emergency medical technicians or paramedics who can perform daily home visits under existing programs – a potentially worrisome step toward deprofessionalizing health care, Batt said. Some caretaking responsibilities also are shifted to families.

Among other concerns, according to Batt and Appelbaum, CMS lacks reliable data on cost-benefit tradeoffs for hospitals, including the volume of patients needed to keep hospital-at-home programs viable, which may exacerbate inequities by favoring large urban hospital systems.

And they say transparency is lacking about the partnerships providing services, including who has authority over medical and billing decisions, how costs and benefits are divided, and who would be legally responsible for medical errors.

Citing past fraud involving surprise medical charges, improper “upcoding” of patients as sicker than they are, and deceptive marketing targeting seniors, the authors caution that “the new hospital-at-home movement may be on the same trajectory.”

Before existing policy is made permanent, the scholars conclude, CMS must establish skills and training standards; patient care metrics; reporting and monitoring systems; and transparent cost-sharing protocols.

“Who benefits from the cost savings?” Appelbaum said. “In the current system, there are too many incentives for hospitals and health care companies, as well as opportunistic financial actors such as private equity and venture capital firms, to make money while leaving patients, families and taxpayers to bear the costs.”

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Becka Bowyer