News & Updates

Regionalization of EMS (and 911 communication centers) has been a growing topic of conversation in local communities, state legislatures, and even Congress.

It often results in more clinically proficient, operationally effective, and fiscally efficient services across larger service areas. It also tends to help with staffing challenges.

During a recent conversation with a member of Congress, we were asked if it would make sense for federal or state governments to support regionalization efforts with incentive funding for consolidation of services.

We were also asked to provide some examples of effective regional EMS systems.

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Rep. Johnson encourages talks of regionalizing EMS

by: Gerry Ricciutti

Aug 21, 2023

https://www.wkbn.com/news/local-news/rep-johnson-encourages-talks-of-regionalizing-ems/

BOARDMAN, Ohio (WKBN) – As local communities wrestle with providing quality emergency medical services across Mahoning County, they heard from a potentially unifying voice.

Monday morning, local fire chiefs, trustees and others heard from Congressman Bill Johnson (R).

“I would want to look at every option and I think they oughta look at regionalization,” Johnson said.

The congressman’s suggestion comes as two local departments, Boardman and Canfield, have been talking about a possible merger for weeks. Boardman is one of only a handful of departments not offering at least some sort of EMS, and the chief says he’d like to see that changed.

“I wanna be part of something that propels this area forward. I think it’s time we really look at things and put our egos aside and do the right thing,” said Boardman Fire Chief Mark Pitzer.

Retired YSU Professor Joe Mistovich was also in the audience and has studied regionalization. He says there have always been roadblocks.

“I think that’s what we need, is somebody from the outside to come in and say, let’s everybody come to the table. Let’s seriously talk about this,” Mistovich said.

Another crucial issue for those in attendance — the levels for Medicare and Medicaid reimbursement for EMS, something the congressman admits will be a very big hurdle to cross over.

Johnson told the group that making changes to the federal system would take time the local communities may not have.

Still, he urged the group to reach out to state lawmakers to see what can be done in Columbus.

“I’m gonna see the governor this evening and I’m gonna whisper in his ear and mention this as well,” Johnson said.

In the meantime, the possible merger between Boardman and Canfield could start taking shape by this time next year.

When the Center for Medicaid sent the attached communication to state Medicaid offices last August, some of us opined that this would be a likely next step in the review of GEMT programs.

It will be very interesting to see which states they choose, the findings from the audits, and what they plan to do if they determine overpayments have been made for uncovered services?

We hope these reviews are done expeditiously, as several state plan amendment (SPA) applications for GEMT programs are being withheld by CMS, pending further review. These delays hurt ambulance providers who are under reimbursed by state Medicaid programs.

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https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000786.asp

Audit of Ambulance Services Supplemental Payment Program

Some States have implemented uncompensated care payment programs that allow ambulance providers to receive supplemental payments for services provided to Medicaid beneficiaries and uninsured patients. We will conduct audits of selected States to determine whether the States' claims for Federal reimbursement for supplement payments to these providers complied with Federal and State requirements.

An EMS partnership with a H@H provider is a logical use of MIH and ambulance resources.

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What the hospital-at-home movement tells us about igniting innovation in health care

By James B. Rebitzer and Robert S. Rebitzer

Aug. 21, 2023

https://www.statnews.com/2023/08/21/hospital-at-home-health-care-innovation/

As a health care economist who studies innovation, and as a management consultant who helps health systems and insurers adopt new technologies, we have had a ringside seat to a frustrating phenomenon: The large private sector of the U.S. health system can move faster to adopt valuable innovations than the public sector burdened by red tape and politics. But before adopting an innovation at scale, the private sector too often waits for the public sector to take the first step — sometimes for decades.

Consider the case of “hospital at home,” a fast-moving, innovative model that delivers acute hospital care to patients in their own homes. Hospital at home has made headlines recently, but it could have achieved scale far sooner if incentives to invest in the model had been properly aligned.

Hospital-at-home programs have been studied since the 1970s. However, neither health systems nor payers were willing to invest in the concept at scale until the official Covid-19 public health emergency, during which the Centers for Medicare and Medicaid Services temporarily allowed Medicare to reimburse for hospital-at-home services under the Acute Hospital Care at Home Waiver.

Since the waiver was adopted in November 2020, hospital at home has taken on the quality of an emerging movement with more and more hospitals participating, driven in part by the rising demand of aging baby boomers and the desire to avoid spending the many billions of dollars needed to build new hospitals. Thanks to an extension from Congress, the waiver remains in effect for now despite the public health emergency declaration ending in March 2023.

Studies find that hospital-at-home programs are associated with reductions in mortality and cost as well as increases in patient satisfaction. So why did the U.S. health sector wait to take up hospital-at-home hospital strategies until a national public health emergency forced CMS to act?

Hospital-at-home programs require substantial upfront investments in new processes, new technologies, and additional specialized personnel. Hospitals will make this investment if they can expect reimbursement sufficient to assure a return on the investment.

These upfront costs create a strategic dilemma for payers. No single payer may have enough enrollees at the hospital to justify reimbursements large enough to cover the hospital-at-home investment. On the other hand, reimbursement could be justified if all the payers agree to reimburse hospital-at-home services, because the costs of the investment would be spread across many more members. Pilot programs may arise here and there, but absent some external coordinating push, no single payer will invest in hospital-at-home at scale.

Economists call this a common-agency problem because it results from many payers contracting with a shared or common agent — here, the hospital. Health care is rife with such problems, which can slow the uptake of valuable innovations for patients and society. But the hospital-at-home story also illustrates how to manage the problem.

The Acute Hospital Care at Home Waiver relieved the common-agency problem by authorizing reimbursement for a significant portion of the hospital’s upfront investment, making it easier for private payers to follow CMS’ lead.

As more private payers support hospital-at-home programs, they strengthen the economic case for other payers by spreading the upfront costs among more members. In this way, hospital at home can move from a novel innovation to a viable way to deliver acute care even though Medicare’s temporary waiver may expire — as it is currently scheduled to do in December 2024.

The example of hospital-at-home illustrates four ways to get innovation moving when adoption seems stalled:

Jump-starting: Commitment to reimbursement by a sufficiently large and influential payer can spark innovation. For hospital at home, CMS played the role of jump-starter of last resort. However, a jump start does not need to come from CMS. For example, commercial payers and self-insured employers with a large enough share of a hospital’s patients can also stimulate adoption.

Information sharing: Incentives alone may not be enough to spur action, particularly for a sweeping innovation like hospital at home. Standard methods and tools are also needed. Bruce Leff, a geriatrician and professor at John Hopkins School of Medicine, and other early innovators in hospital at home have formed the Hospital at Home Users Group to share best practices for the design and implementation of hospital-at-home programs.

Reducing uncertainty and enhancing confidence: The temporary Acute Hospital Care at Home Waiver was enough to get adoption started in some hospitals. However, if the waiver were made permanent, uncertainty about the program would be reduced and progress would likely be faster and more widespread. Congress has extended the waiver once since the public health emergency ended but only on a temporary basis. The waiver is currently scheduled to expire in December 2024.

Creating a professional and social consensus: When innovations further the goals of health and healing, rather than pecuniary interests, professional and social norms can help overcome incentive problems. Institutional support is also critical for building consensus. Both the American Hospital Association and the Society of Hospital Medicine have reported favorably on hospital-at-home programs, helping create support for change among providers and the public.

Sometimes the complex and pluralistic U.S. health care system can be slow to innovate. In such cases, aligning incentives for all parties to participate fully may be just what is needed to get things moving.

James B. Rebitzer is the Peter and Deborah Wexler professor of management at Boston University’s Questrom School of Business. Robert S. Rebitzer is a national adviser at Manatt Health. Formerly he was a partner in the health care strategy practice at Accenture and a vice president of UnitedHealth Group. They are the authors of “Why Not Better and Cheaper?: Healthcare and Innovation.”

Some fire departments are responding to fewer medical calls, here's why

Johnathan Hogan

Port Huron Times Herald

August 13, 2023

https://www.thetimesherald.com/story/news/local/2023/08/13/local-fire-departments-are-responding-less-to-non-emergency-medical-calls/70573039007/

The next time you call 911 to report a medical emergency, it's less likely a firefighter will join EMS responders.

A new protocol adopted by several St. Clair County fire departments has changed how they coordinate with Tri-Hospital Emergency Medical Services to respond to medical calls.

With a few exceptions, fire departments will only respond to medical incidents classified as protocol Delta or protocol Echo, the most serious and life-threatening medical incidents.

The change in emergency response was made to reduce the risk that firefighters will all be tied up in non-emergency calls in the event of a structure fire or other major incident only the fire department could address.

When will you see the fire department respond to your medical emergency?

Previously, both firefighters and Tri-Hospital EMS would respond to calls classified as Bravo and Charlie, the mid-level classification of calls, as well as Delta and Echo. Now, firefighters will no longer respond to those mid-level, non-emergency calls.

Exceptions will be made if it would take more than eight minutes to respond to the emergency.

Tri-Hospital EMS will still respond to all medical calls they receive, according to Ken Cummings, the CEO. The policy change applies only to firefighters. 

The St. Clair County Medical Control Authority adopted the new policy in February after receiving a unanimous endorsement from county fire department chiefs and a draft of the recommended changes. The policy change officially took effect in April.

The recommendation to change the policy came after the county fire departments and the Medical Control Authority conducted a study to learn how to reduce the number of responses by firefighters.

In recent years firefighters and other emergency responders have seen staffing decreases. Fire departments have seen less applications in new job postings even as the number of calls increases each year, so local fire chiefs looked for ways to reduce non-serious calls to make sure a team is always available in case of a fire.

Port Huron Township Fire Department Chief Andrew Persig endorsed the change in a presentation to Port Huron Township officials at a July 17 meeting.

“Responding to non-emergency incidents ties up fire personnel and makes them unavailable during an incident where firefighters are actually needed,” Persig wrote in a presentation.

Sixteen of St. Clair County’s fire departments have accepted this change. Six, however, have adopted an alternate policy of responding to every single medical call, regardless of the classification. Those include Kimball Township, Algonac Fire Department, Grant Township Fire Department, Greenwood Township Fire Department, Ira Township Fire Department and Kenockee Township Fire Department.

Cummings, who is a member of the Medical Control Authority, said firefighters who went to Bravo and Charlie calls sometimes had little to do to help emergency medical technicians on a call.

“There were times where all they would do is hold open the door,” Cummings said. “Clearly, that’s an unnecessary use of resources.”

Interesting report from News4 Detroit on the ongoing EMS staffing issues in Detroit Fire Department.

The latest example that the staffing crisis is impacting EMS agencies across the country, regardless of provider type.

https://www.youtube.com/watch?v=WDwPu79n_fc

More trouble for the IDR process…

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Surprise billing arbitration halted (again)

Tina Reed

8/7/23

https://www.axios.com/newsletters/axios-vitals?id=2&name=Vitals&screen=channel

The process providers and insurers use for settling surprise billing disputes was halted after a federal court found the Centers for Medicare and Medicaid Services improperly hiked the fee for requesting arbitration.

Why it matters: It's another hiccup for the arbitration system, known as the independent dispute resolution process. It's also the second time this year the IDR process has been halted after a court ruling.

What happened: A federal judge sided with the Texas Medical Association in a lawsuit that argued CMS failed to follow proper notice-and-comment procedure when it raised the fee for participating in the IDR process from $50 to $350. CMS upped the fee in December, citing "increasing expenditures in carrying out the Federal IDR process."

• CMS on Friday evening said it temporarily suspended the IDR process, including the ability to file new disputes.

Catch up quick: The arbitration system has been loaded up with disputes, meaning some cases have dragged on for months. Some providers have also recently complained that insurers have ignored or failed to fully adhere to arbitration rulings.

• The IDR system was paused for about five weeks earlier this year after the same Texas physician group challenged a separate part of the IDR process, which it said favored insurers.

Something for us to keep in mind as we go through the GAPBAC process and efforts to potentially use arbitration as a solution….

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Docs say insurers ignore surprise billing decisions

Tina Reed

August 3, 2023

https://www.axios.com/newsletters/axios-vitals?id=2

Insurers are sometimes ignoring rulings to pay providers, or failing to pay them in full, under the arbitration system established by the new federal surprise billing law, providers tell Axios.

Why it matters: The No Surprises Act, a bipartisan effort to limit unexpected out-of-network medical bills, required that insurers and providers undergo an independent arbitration process to settle their differences without involving patients. The complaints from providers are the latest snag with the arbitration system that launched last year.

Driving the news: Some providers say they received letters from insurers explicitly saying they won't honor an arbitration award because they view them as "unenforceable" and "not binding," according to the Americans for Fair Health Care, a coalition of clinical and advocacy organizations.

• The leading trade groups representing doctors and hospitals also said they've heard complaints from their members about not receiving arbitration awards. "This undermines the careful balance Congress struck in the No Surprises Act and threatens to destabilize already financially strapped providers," said Molly Smith, vice president of policy for the American Hospital Association.

The other side: Insurers have said providers are bogging down the arbitration system with frivolous challenges to billing decisions. They also say arbitrators are bundling multiple decisions together in a way that's contributing to administrative delays.

What they're saying: The Centers for Medicare and Medicaid Services and other federal agencies regulating surprise billing have received a number of complaints regarding late payments following arbitration, a CMS spokesperson confirmed.

• The agency "is actively investigating and addressing complaints regarding late payments," the spokesperson said, adding the statute is clear that the arbitration process is binding unless there is evidence of fraud.

What we're watching: Whether CMS will make further changes to the arbitration process in response to providers' complaints — or whether litigation challenging that system, such as one lawsuit from the Texas Medical Association, may force the agency's hand.

The wage war, especially in public safety, is likely not sustainable. A recent study by the National Emergency Number Association (NENA) found that 82% of centers reported being understaffed and struggling with hiring and retention, with respondents citing stress and low pay as the top obstacles to attracting and keeping staff.

This is one reason communities are considering, and DOING, regional consolidation of services.

It is also a primary reason for the EMS worker shortage, leading agencies to require funding to raise front-line wages to maintain staffing and service levels.

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Mounting job vacancies push state and local governments into a wage war for workers

BY DAVID A. LIEB

July 28, 2023

https://apnews.com/article/state-job-vacancies-pay-raises-wage-war-74d1689d573e298be32f3848fcc88f46

FULTON, Mo. (AP) — At the entrance to Missouri prisons, large signs plead for help: “NOW HIRING” ... “GREAT PAY & BENEFITS.”

No experience is necessary. Anyone 18 and older can apply. Long hours are guaranteed.

Though the assertion of “great pay” for prison guards would have seemed dubious in the past, a series of state pay raises prompted by widespread vacancies has finally made a difference. The Missouri Department of Corrections set a record for new applicants last month.

“After we got our raise, we started seeing people come out of the woodwork, people that hadn’t worked in a while,” said Maj. Albin Narvaez, chief of custody at the Fulton Reception and Diagnostic Center, where new prisoners are housed and evaluated.

Public employers across the U.S. have faced similar struggles to fill jobs, leading to one of the largest surges in state government pay raises in 15 years. Many cities, counties and school districts also are hiking wages to try to retain and attract workers amid aggressive competition from private sector employers.

The wage war comes as governments and taxpayers feel the consequences of empty positions.

In Kansas City, Missouri, a shortage of 911 operators doubled the average hold times for people calling in emergencies. In one Florida county, some schoolchildren frequently arrived late as a lack of bus drivers delayed routes. In Arkansas, abused and neglected kids remained longer in foster care because of a caseworker shortage. In various cities and states, vacancies on road crews meant cracks and potholes took longer to fix than many motorists might like.

“A lot of the jobs we’re talking about are hard jobs,” said Leslie Scott Parker, executive director of the National Association of State Personnel Executives.

Lingering vacancies “eventually affects service to the public or response times to needs,” she added.

Workforce shortages worsened across all sorts of jobs due to a wave of retirements and resignations that began during the pandemic. Many businesses, from restaurants to hospitals, responded nimbly with higher wages and incentives to attract employees. But governments by nature are slower to act, requiring pay raises to go through a legislative process that can take months to complete — and then can take months more to kick in.

Meanwhile, vacancies mounted.

In Georgia, state employee turnover hit a high of 25% in 2022. Thousands of workers left the Department of Corrections, pushing its vacancy rate to around 50%. The state began a series of pay raises. This year, all state employees and teachers got at least a $2,000 raise, with corrections officers getting $4,000 and state troopers $6,000.

The Georgia Department of Corrections used an ad agency to bolster recruitment and held an average of 125 job fairs a month. It’s starting to pay off. In the first week of July, the department received 318 correctional officer applications — nearly double the weekly norm, said department Public Affairs Director Joan Heath.

Almost 1 in 4 positions — more than 2,500 jobs -- were empty in the Missouri Department of Corrections late last year, which was twice the pre-pandemic vacancy rate in 2019.

Missouri gave state workers a 7.5% pay raise in 2022. This spring, Gov. Mike Parson signed an emergency spending bill with an additional 8.7% raise, plus an extra $2 an hour for people working evening and night shifts at prisons, mental health facilities and other institutions. The vacancy rate for entry level corrections officers now is declining, and the average number of applications for all state positions is up 18% since the start of last year.

At the Fulton prison, where staff shortages have led to a standard 52-hour work week, newly hired employees can earn around $60,000 annually — an amount roughly equal to the state’s median household income. The prison also is proposing to provide free childcare to correctional officers willing to work nights.

If prison staffing is too low, “it can get dangerous” for both inmates and guards, Narvaez said.

Public safety concerns also have arisen in Kansas City, where a country music fan attacked before a concert last month waited four minutes for a 911 call to be answered and an hour for an ambulance [from Kansas City Fire Department] to arrive. About one-quarter of 911 call center positions are vacant — “a huge factor” in the longer wait times to answer calls, said Tamara Bazzle, assistant manager of the communications unit for the Kansas City Police Department.

In Biddeford, Maine, a 15-person roster of 911 dispatchers dipped to just eight employees in July as people quit a “pressure cooker job” for less stress or better pay elsewhere, Police Chief JoAnne Fisk said. The city is now offering fully certified dispatchers $41 an hour to help plug the gaps on a part-time basis — $10 an hour more than comparable new workers normally would earn.

This month, Biddeford also launched a $2,000 bonus for city employees who refer others who get jobs. That comes a year after Biddeford adopted a four-day work week with paid lunch periods to try to make jobs more appealing, said City Manager Jim Bennett.

To attract workers, other governments have dropped college degree requirements and spiced up drab job descriptions.

Nationally, the turnover rate in state and local governments is twice the average of the previous two decades, according to federal labor statistics.

Uncompetitive wages were the most common reason for leaving cited in exit interviews, according to a survey of 249 state and local government human resource managers conducted by MissionSquare Research Institute, a Washington, D.C. -based nonprofit. The hardest positions to fill included police and corrections officers, doctors, nurses, engineers and jobs requiring commercial driver’s licenses.

Along Florida’s east coast, the Brevard County transit system and school district have been competing for bus drivers. On days when drivers are lacking, the transit system has cut the frequency of bus stops on some routes. The school system, meanwhile, has asked some bus drivers to run a second route after dropping children off at school, often resulting in the second busload arriving late.

Since 2022, the county has twice raised bus driver wages to a current rate of $17.47 an hour. The school board recently countered with a $5 increase to a minimum $20 an hour for the upcoming school year. The goal is to hire enough drivers to regularly get kids to class on time, said school system communications director Russell Bruhn.

In Arkansas, the goal is to get foster kids into permanent homes in less than a year. But during the first three months of this year, the state met that target for just 32% of foster children — well below the national standard of over 40%. More than one-fifth of the roughly 1,400 positions in the Arkansas Division of Children and Family Services are vacant.

Many new employees leave in less than two years because of heavy caseloads and the “very difficult, emotionally tolling work,” Mischa Martin, the Department of Human Services’ deputy secretary of youth and families, told lawmakers last month.

“If we had a knowledgeable, experienced workforce,” she said, “they would be able to work cases in a better way to get kids home quicker.”

The most recent example of the staffing and funding crisis being faced by public safety agencies across the country….

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Calaveras County fire station to be closed some days due to low staffing

Sacramento

BY STEVE LARGE

JULY 30, 2023

https://www.cbsnews.com/sacramento/news/calaveras-county-fire-station-to-be-closed-some-days-due-to-low-staffing/

VALLEY SPRINGS — "Closed due to staffing" — the message draped across a Calaveras Consolidated Fire Protection District station reads loud and clear.

The chief said he has no choice.

This weekend, the fire district was forced to brown out one of its two fire stations for a day, and more closures are ahead. Chief Rich Dickinson said that big banner, with letters written in fire engine red, is the best way to let his community know.

Chief Dickinson said it's a decision he wishes he didn't have to make.

"We're going to be browning out more. I decided to buy that sign, to put it upfront so that people understand the firehouse is closed and why it's closed," he told CBS Sacramento via Zoom.

The fire district's staff is now down to just 13 firefighters, and Chief Dickinson said he's lost 40 since he started here six years ago.

The attrition problem comes from competition and San Francisco Bay Area fire department compensation.

"To be honest, the staff that I have left, they're working a lot of hours," Dickinson said. "And at some point, there's a breaking point."

The Calaveras Consolidated Fire District covers 168 square miles with only two operating stations, one of which will now be closed some days due to low staffing.

Dickinson is proposing a tax hike next year to help solve the money trouble. In the meantime, the banner will be up when this fire station is closed down.

"I'm not being vindictive. I'm not being a chief that's trying to go 'OK, you want to play hardball?' " he said. "I don't want that. It hurts me to not have that fire station open. It hurts the board. It hurts the firefighters. Nobody feels good about that."

Last year, Calaveras County voters denied a tax increase that would have increased funding for nine fire districts. Richardson hopes to have a new measure for his district on a ballot next spring.

These 2 articles are a nice primer on the Hospital @ Home model.

They explain the model, and highlight the reasons for growth, potential challenges to growth, and the increasing role of EMTs and paramedics in the H@H model.

Some innovative H@H agencies are partnering with transformative EMS agencies, including we here at MedStar, to deliver episodic and routine care using trusted, local providers.

Imagine a day when an EMS response results in the EMS crew using telemedicine to ‘admit’ the patient to the hospital, at home, and the patient does not require transport to the hospital… 

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Why home is becoming the future for hospitals

DIANE EASTABROOK

June 07, 2023

https://www.modernhealthcare.com/providers/hospital-at-home-medicare-payor-cms-john-hopkins

More than 400 hospitals and hospital systems have hospital-at-home programs, despite uncertainty over what future reimbursements might look like under Medicare.

Hospital-at-home has exploded since the COVID-19 pandemic and is expected to grow 50% over the next few years due to an increase in the number people over age 65, including 72 million baby boomers. Hospitals say treating patients at home can reduce healthcare costs and improve patients' emotional well-being as they recover with family and friends.

Here is what you need to know about the growing hospital-at-home trend.

What is hospital-at-home?

Hospital-at-home allows patients who need acute care to receive treatment in their homes, rather than in a hospital. Providers use remote patient monitoring to keep an eye on patients' vital signs. They also rely on laptops or other mobile devices to communicate with patients and caregivers. Congestive heart failure, pneumonia and COVID-19 are a few of the illnesses often treated through the model. The program allows hospitals to free up beds for the sickest, more costly patients, while still providing care to other patients at home at a reduced cost to providers and the payers.

Is it a new care model?

Hospital-level treatment at home has been around since the 1970s in the United Kingdom, Canada and Israel. It came to the U.S. in 1995 when Johns Hopkins School of Medicine and Public Health in Baltimore piloted hospital-at-home. Johns Hopkins found the program reduced inpatient stays and lowered overall medical costs by a third. By 2002, Johns Hopkins, Presbyterian Health Services in Albuquerque, New Mexico, and a half dozen Veteran Administration medical centers began offering the care model.

What impact did the COVID-19 pandemic have?

The pandemic accelerated the care model's growth. In March 2020, the Centers for Medicare and Medicaid Services launched the Hospital Without Walls initiative to help hospitals overwhelmed with COVID-19 patients increase capacity. Eight months later, CMS expanded the program as Acute Hospital Care At Home, giving hospitals greater flexibility to treat patients at home and receive the same reimbursement rates as patients in hospitals. By the middle of 2021, nearly 170 hospitals and health systems in 29 states offered hospital-at-home. Today 406 hospitals and health systems in 33 states offer the program. Congress extended the reimbursements until the end of 2024.

What are the requirements of hospital-at-home?

CMS requires hospitals to carefully screen patients for medical and non-medical factors, such as suitability of the home. Patients are typically enrolled in the program from emergency departments or inpatient beds by a physician. They must be evaluated daily by a doctor or advanced practice nurse either in-person or virtually. Patients must also be evaluated remotely or in-person twice a day by a registered nurse or a paramedic. Hospitals must provide an on-demand connection to a nurse or physician at a command center who must be able to respond within 30 minutes if a patient's physical or mental health is deteriorating. Providers must also be able to connect patients to other necessary services, such as meals, pharmacy and laboratory tests.

Who are the key players?

Johns Hopkins, Rochester, Minnesota-based Mayo Clinic, Oakland, California-based Kaiser Permanente and Cleveland, Ohio-based Cleveland Clinic are among the largest hospital systems offering hospital-at-home. A handful of companies partner with hospitals to provide one-stop shopping to set up the programs. Those companies include Boston, Massachusetts-based Medically Home and Biofourmis, as well as Nashville, Tennessee-based Contessa Health, which is a unit of Amedisys. Those companies coordinate staffing, provide command centers, remote patient monitoring and offer a variety of other turnkey solutions.

What is the market's growth potential?

Healthcare research firm Chilmark forecast the hospital-at-home market would grow from approximately $200 billion in 2023 to $300 billion by 2028. Chilmark analyst Elena Iakoveva said technology and healthcare disrupters, including Amazon and Best Buy, could add hospital-at-home services to their healthcare offerings that include One Medical and Current Health, respectively.

What might slow its growth?

There are no guarantees Medicare and private health insurers will continue to reimburse hospitals at the same rate for patients receiving care at home versus the hospital. The concept also faces barriers in rural areas that often lack reliable internet service to connect patients to medical staff. And the nursing shortage could make it difficult for hospitals to deploy enough clinicians to make the necessary visits, especially to remote areas. While nurses in hospitals can care for several patients at one time, nurses deployed to homes may only care for four or five patients a day. Patient preference and safety are two other challenges. Many patients still would rather receive care in a hospital and others may not have in-home support from family caregivers to safely stay at home. Some family members who act as caregivers may also lack the skills necessary to help care for a very sick patient.

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Payment concerns not stopping new hospital-at-home programs

DIANE EASTABROOK

July 27, 2023

https://www.modernhealthcare.com/providers/home-health-hospital-at-home-medicare-reimbursement

Hospital-at-home is attracting a new field of providers who say they can sustain the model despite uncertainty over how Medicare will reimburse for the service in the future. Home health agencies and even senior living companies are launching versions of hospital-at-home that don’t rely on reimbursement from Medicare fee-for-service.

The CMS Acute Hospital at Home Waiver launched in November 2022, which allows hospitals and health systems to treat patients outside of their walls, is set to expire at the end of 2024. Medicare reimburses hospitals at the same rate for in-home care as it does for an in-facility stay. However, the waiver requires patients to visit an emergency department or be a patient in a hospital before being transferred to hospital-at-home.

But other payers don’t have that requirement, making it easier for home health agencies and other providers to launch hospital-at-home programs without the threat that Medicare reimbursement might change.

Senior health company Lifespark, which provides primary care, home health and hospice services, and owns 40 senior living facilities in Minnesota and Wisconsin, plans to launch a hospital-at-home program by year's end. The St. Louis Park, Minnesota-based company piloted a similar program in partnership with North Memorial Hospital in Minneapolis for about six weeks in 2020 during the COVID-19 pandemic.

Lifespark takes on full risk for approximately 25,000 older adults through value-based care arrangements with Medicare Advantage plans. Founder and CEO Joel Theisen said the hospital-at-home program under development would target those patients and will likely include collaboration with hospitals.

“We can intercept at the hospital and transition [them] early to acute-care-at-home, " Theisen said.

Home health providers CenterWell, Elara Caring, Enhabit and Home Instead have forged partnerships in recent months with in-home healthcare provider DispatchHealth to provide hospital-level care to clients. The Denver-based company sends emergency medical technicians and nurse practitioners into the homes to evaluate patients under the virtual direction of a physician. Patients requiring hospital-level care can be enrolled in DispatchHealth’s acute-care-at-home program. The service is covered under many Medicare Advantage plans, managed Medicaid plans and private health plans.

“We essentially receive a bundled payment for that episode and we provide all of the necessary care,” said DispatchHealth Founder and CEO Dr. Mark Prather.

Healing Hands, a Dallas-based home health company, launched hospital-at-home in 2018 and gets reimbursed through the CMS' home health prospective payment system. Payments cover nursing care, telehealth, remote patient monitoring and home healthcare–all components of hospital-at-home.

Healing Hands CEO Summer Napier said her company identifies those home health clients whose conditions are deteriorating and require acute-level care, and then works with primary care physicians to transition those patients to its hospital-at-home program. Napier said Healing Hands has provided hospital-at-home care to approximately 900 patients so far.

The home health model could provide a possible guide to CMS as it considers the future of hospital-at-home reimbursement after the Medicare waiver expires. A study last year by healthcare consultancy Milliman said designing a Medicare reimbursement approach for hospital-at-home based on a home health payment, with additional payments for expanded services, could be less costly than a hospital-centered payment.

A home health-based Medicare fee-for-service payment could encourage more home health providers to add hospital-at-home. But Dr. Robert Moskowitz, chief medical officer for hospital-at-home company Contessa Health, said it can be challenging for some home health agencies to scale hospital-at-home if they don’t have the appropriate technology or staff.

“A lot of home health entities might be employing home health nurses, but they’re not used to that [higher] level of acuity,” Moskowitz said. “You’ve got to have the comfort level of competency for the nurse providing the care.”