“Waiver Program is Difficult”: Problems with the CMS Hospital-at-Home Program


The proliferation of home hospital models has been one of the main trends in home care during the COVID-19 crisis, and players on all sides are optimistic that this trend will continue after the end of the crisis. pandemic.

The US Centers for Medicare & Medicaid Services (CMS) “Acute Hospital Home Care” dispensation program has enabled more health systems and home care agencies to become involved. But some participants believe that the waiver program – as currently designed – is not the best way forward for the concept.

The MultiCare healthcare system based in Tacoma, Wash., For example, offers two different home hospital models. One model is the waiver program and the other is its own partnership with home health care provider DispatchHealth.

The types of patients in these two programs are the same, but the way he identifies them is different. One method works and the other doesn’t, Christi McCarren, senior vice president of retail health and community care for MultiCare, recently told the Home Health Care News FUTURE conference.

“The waiver program – although well intentioned – is difficult,” McCarren said.

MultiCare is a non-profit healthcare organization that operates seven hospitals in Washington State.

There are currently 77 health systems and 177 hospitals in 33 states approved for acute hospital home care, according to CMS.

In the waiver program, patients land in the emergency room, then they must meet the admission criteria and the conditions for participation. If all goes well, they can be sent home.

However, thanks to its partnership with DispatchHealth – announced at the end of 2020 – MultiCare is able to identify patients hospitalized at home before they enter the hospital, in the community.

For its part, Denver-based DispatchHealth is partnering with health systems like MultiCare and payers to provide a range of in-home services. Its healthcare teams and mobile units are available every day of the week and help meet patient needs in order to reduce hospitalizations and other adverse health events.

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

The perception that home care is less effective than hospital care is what makes it difficult to waive.

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“[For instance], if you’ve spent hours with sick and sick relatives, and you finally take them to the emergency room, and a nice person comes to you and says, “We would like to send you home,” will you say yes ? McCarren said. “You’re dead tired, you’re uncomfortable sending them home, and Grandma herself says, ‘What do you mean I can’t go to the hospital? Am I not good enough? What I’m saying here is that we need to move beyond this perception that this is substandard care, which it is not. It’s exactly the same, and probably better.

The acceptance rate of the two programs operated by MultiCare speaks volumes. For the CMS program, the rate is around 25% – “a good month” – while the advanced care program has an acceptance rate of around 98%, McCarren said.

“[It’s 98%] because it is identified when a patient is already at home and no longer needs to move, ”she said. “So what’s flawed about the CMS dispensation program is the way we identify patients and actually bring them into the program. You have to overcome this patient perception. You also rely on emergency room doctors who are busy identifying patients as soon as they walk through the door – is this going to happen in every facility? This does not happen in mine.

Savings and results

Regardless of further developments in the Acute Hospital Home Care program, healthcare systems and providers will continue to invest in the concept.

Where it initially offered a way to unclog overcrowded hospitals, 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 at home, you’ll get dramatically improved results,” said Dr Mark Prather, co-founder and CEO of DispatchHealth. in the future. “And we’ve seen it ourselves here.”

The objective of DispatchHealth is essentially to bring emergencies – which represent 85% of admissions – home.

This is possible thanks to its mobile units, which are equipped with almost all the equipment that patients would need in the hospital during an admission.

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

Additionally, when patients are admitted to the hospital, they spend significantly more time in bed than they would if they were at home, McCarren noted. Their health issues then they may end up in an institution when they ultimately could have avoided that.

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

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