Mount Sinai: Hospital at Home and Rehabilitation at Home services using existing Medicare-reimbursable services: Opportunities, Costs, Gaps and Contingencies

Hospital at Home (HaH) programs provide seniors and other at-risk patients with home-based care better matched to their wishes and needs, while also providing a lower cost alternative to hospitalizations. Numerous conditions common to older adults including treatment of exacerbations of chronic diseases have been effectively treated in the comfort and safety of the home setting. Established benefits include shorter lengths of acute treatment, lower rates of 30-day hospital admissions/readmissions, emergency department visits, and skilled nursing facility admissions as well as better patient experiences.

There have been experiences at Mount Sinai, using CMMI funding, in combining the HAH program with Rehabilitation at Home (RaH) (providing subacute services at home)—a program that allows for sharing of staffing infrastructure while delivering a needed service to patients.

Efforts to develop a bundled payment for HaH episodes plus 30-day care have been established with some commercial insurance companies, while efforts to secure the HaH model as a permanent paid benefit in traditional Medicare are ongoing. The HaH payment bundle is currently not available to most potentially-eligible beneficiaries, including most traditional Medicare patients. A payment method for RaH is similarly lacking.

For this reason, in 2018, the Institute collaborated on a study of how payment for HaH and RaH services might be restructured out of existing Medicare and other fee-for-service-oriented payment mechanisms.

The results will aid the understanding of the breadth of opportunity for providing HaH and RaH care to a larger number of Medicare beneficiaries particularly those in value- and risk-based arrangements, such as ACOs, using the existing “chassis” of Medicare FFS reimbursement. While numerous health systems recognize and embrace the overall transition from volume to value-based care, they generally operate at margins that preclude extensive investment in non-reimbursable services, despite the potential for future returns.

Importantly, findings from the study could also clarity specific gaps in coverage (necessary services or treatments with no reimbursement mechanism when delivered in a home setting), which could, in turn, provide better specificity to support the ongoing messaging back to Medicare concerning the need for a comprehensive-bundled payment, or alternative provisions that directly exploit this opportunity for lowering the cost of healthcare.