Although health systems received an extension of the CMS Acute Hospital Care at Home waiver, it has been more of a challenge to get state Medicaid programs to participate. So far, eight state Medicaid programs are paying for acute care at home. During a Sept. 19 webinar, officials from Illinois, Massachusetts, and North Carolina described the efforts to engage with Medicaid in their states.
The eight state Medicaid agencies paying for hospital at home are in Arizona, Arkansas Massachusetts, Michigan, Oregon, Oklahoma, South Dakota and Texas.
The nonprofit Hospital at Home Users Group, in partnership with the American Academy of Home Care Medicine, presented the webinar moderated by Albert Siu, M.D., who directs Mount Sinai’s Institute for Care Innovations at Home. “When we started our hospital at home at Mount Sinai almost 10 years ago, I remember going around to leadership and others in the community to advocate on behalf of the hospital at home program. One of the comments that I got back off was that you're really only going to be able to do this the apartments of wealthy people, who would have enough room for the entire team,” Siu recalled. “And I had to really correct this misconception because we really viewed hospital at home from the vantage point of equity and wanting to provide this to all of our community. In our multi-payer system in this country, it is hard to achieve equity without Medicaid and hence the topic of this webinar.”
Seeking Medicaid coverage in Illinois
Blessing Health System in rural Quincy, Ill., was the first hospital at home program in the state of Illinois and to date is the only rural home hospital in the state. It started with a partnership with Ariadne Lab on a home hospital randomized controlled trial in 2021. They were granted the CMS waiver late that year and their program started in February 2022. They enrolled 50 patients in the trial, which finished up in August 2023. The program is continuing outside of the trial. Blessing’s payer mix includes 14 percent Medicaid patients. “We did recognize early in our journey that it would be important to be able to secure funding for that Medicaid population,” said Mary Frances Barthel, M.D., chief quality and safety officer, for Blessing Health System. She got in touch with the medical director for the Illinois Department of Health Care and Family Services. “We talked about the CMS waiver, and I gave him the details of our randomized controlled trial patient selection, and some of our processes and procedures. He was very open to learning more about hospital at home, but also wanted to see the results of our randomized controlled trial and also see just how hospital at home was going to develop nationwide before committing much.”
In the meantime, other hospital at home programs have gotten up and running in Illinois. Currently there are five health systems that have the CMS waiver and are actively enrolling patients. Besides Blessing Hospital, they include Northwestern, the University of Chicago Health system, University of Illinois at Chicago and OSF. “The five of us started a partnership where we have monthly phone calls to discuss any mutual issues and growing pains,” Barthel said. “On Sept. 1, we had a Zoom call with representatives from Health and Family Services, and presented the background on each of our programs as well as an overview of some of the research that's been done to date on outcomes in hospital at home. One of the surprising takeaways from that phone call was that we really needed to go back to basics. We made an assumption that that team had familiarity with the nuts and bolts of hospital at home and some of the history and they really didn’t. We did go back to some of those basics and talk about patient selection and design of the programs. They wanted to know a lot of detail about patient monitoring and caregiver support,” she added.
The state Medicaid officials asked a lot of questions about quality and safety metrics collection and reporting. They were curious about the future of the CMS waiver and the process that Medicare would have to go through to make that permanent, should they decide to make that permanent. “They asked me about any concern about impacting critical access hospitals by diverting some of those patients into the hospital from home rather than going to those smaller rural hospitals,” Barthel added. “And we talked a lot about health equity and access to care. They asked if the State of Illinois decides to go forward with this, how, how do they even go about doing that? I sent them some contact info from the state of Massachusetts so that that the administrators in Illinois can reach out directly.”
On again, off again in North Carolina
Miriam Tardif-Douglin, M.S.P.H., is senior program manager, research and policy, at CaroNova, a nonprofit incubator that advances promising innovations in healthcare. Shegave a basic timeline of progress in North Carolina. In November of 2020 CMS announced the hospital at home waiver. In September 2021, the Division of Health Benefits (DHB), which oversees the Medicaid program, began paying for hospital at home. At the same time CaroNova and Ariadne Labs launched a home hospital early adopters accelerator program. In March of 2022 DHB ended home hospital coverage in North Carolina. In July 2023 DHB shared with hospitals and managed care plans mixed outcomes on the North Carolina Medicaid home hospital population. That same month, CaroNova and the North Carolina Health Care Association and member hospitals adopted the home hospital early adopter accelerator’s social and environmental inclusion criteria to allay some DHB concerns. In August 2023 DHB stated some continued interest in home hospital coverage, but also some outstanding questions about some of the risks.
“By ending Medicaid coverage, the unintended effect was to make access to home hospital less diverse and in that way less equitable,” Tardif-Douglin said. “Having coverage by Medicaid really has a large impact on whether certain patients and certain demographics can access a program that is proven to be valuable not just for all patients but specifically for Medicaid patients.”
DBH had concerns that the living circumstances and poverty of Medicaid patients precluded safely offering the program in their homes, Tardif-Douglin said. “This is despite published research that showed statistically significant changes in ED visits favoring home hospital among Medicaid patients,” she added.
The hospitals adopted the social and environmental inclusion criteria to try to allay some of these concerns. The criteria include housing and utilities, safety, substance use, caregiver ability, patient mobility, patient capacity for decisions and insurance. “The message was that this this is evidence of the precautions that home hospital programs in North Carolina are taking to make sure that Medicaid patients in the program are not having poor outcomes because they were admitted despite having home conditions that counter-indicated home hospital such as a lack of running water or no working telephone.”
“In order to get Medicaid reimbursement for home hospital, we found the most important thing was recognizing and responding collaboratively to DHB concerns about home hospital,” Tardif-Douglin added. This is an alternative to the approach of trying to just educate them without as much of a focus on really listening to what their concerns are, and validating those concerns.
“Other important factors were conversations with policymakers and evidence of widespread buy-in among hospitals and showing that there's this groundswell of support stories of patients wanting the service, and published literature that shows the benefits of the service, as well as concise clear documentation of standards to ensure safe delivery of care,” she said.
Leading the way in Massachusetts
Massachusetts was a pioneer in terms of Medicaid coverage for hospital at home. Chuck Pu, M.D., senior medical director in the Office of Long-Term Services and Supports at Massachusetts Medicaid (MassHealth), gave a timeline of Massachusetts Medicaid’s coverage of hospital at home. November 2020 was when CMS launched its official acute hospital at home waiver program, and that was to expire at the end of the pandemic. “One of our proudest moments as a state Medicaid agency was that three months after CMS released its acute hospital at home waiver, MassHealth issued bulletin 180. That was in February 2021, and basically we became the first state Medicaid agency in the country to cover hospital at home,” Pu said. That was soon followed by an announcement that MassHealth managed care entities had to cover hospital at home as well for Medicaid members.
In January of 2022 CMS advanced this initiative by declaring new specific hospital at home codes. And then in December of 2022 through the Consolidated Appropriations Act, it extended hospital at home through the end of 2024. “This past year has been a busy year for MassHealth and hospital at home, as we have had the opportunity to share some of our state Medicaid experience internationally and nationally at hospital at home conferences. When they looked at data about how hospital at home touched 255 individuals who were on MassHealth Medicaid and they were encouraged by the outcomes. After nearly three years, hospital at home admissions among MassHealth members has topped 900 encounters. “It makes up less than 1 percent of all hospital admissions among MassHealth members, but it's getting close to 1 percent,” Pu said.
“We have a total of 19 CMS hospital at home waiver-approved hospitals in Massachusetts making up about 31 percent of our 61 hospitals, covering six to seven health systems. And in just in the past year, those numbers have doubled, with 13 new programs, and many of them are just about to launch.”
Pu said MassHealth is developing a policy framework to scale and evaluate this model. There are legislative and regulatory issues, such as how should Medicaid programs conduct utilization management and assess program integrity and address health equity. “We are about to launch our first publicly facing hospital at home dashboard,” he said. “We're just going to show how many hospital at home admissions have happened in this year and how many hospital at hospital and home admissions per program. We feel it's a small but significant step to increase awareness.”