During a short Thanksgiving work week, the Centers for Medicare & Medicaid Services (CMS) found time to make two pretty significant announcements. The first is that they are now accepting waiver requests from hospitals to offer true at-home services. In this program, instead of admitting patients requiring hospital care to the hospital, they will be able to send the patient home and provide them hospital-level care in their home. How does CMS define “hospital-level care at home?” Well, there are not many details, but there will need to be three visits per day by medical personnel, with at least one of those visits being by a registered nurse (RN). The other two can be by a nurse or a paramedic, along with a daily doctor visit.
Now, at face value, this makes no sense at all. Patients are put in the hospital because they need to have immediate access to medical personnel, 24 hours a day. We don’t send patients with a transient ischemic attack (TIA) home with a hep lock and a syringe of tPA and tell them to FaceTime the doctor for instructions on how to give themselves an injection if they have another neurologic episode. A chronic obstructive pulmonary disease (COPD) patient needing frequent nebulizers, at risk of respiratory failure, cannot be sent home with instructions on how to use a leaf blower to do home biPAP if their breathing gets worse. And how does a doctor order a stat X-ray or blood test in a home setting?
The patients who qualify for this program will have to be carefully selected, and probably would be unlikely to pass MCG or InterQual criteria for inpatient admission, even though that is not the standard by which Medicare determines admission appropriateness. A review of a study of a hospital at-home program at a major Boston-area health system, published in the Annals of Internal Medicine, showed very strict inclusion and exclusion criteria, including excluding patients over the age of 65 for many diagnoses, and a limit of five patients at one time in the program, along with a five-mile distance limit from the hospital for the patient’s residence.
It also worries me that insurance companies that are already unwilling to approve inpatient admission for anyone but the patient at death’s door will see this program as another excuse to deny more admissions and observation stays, telling hospitals that the patients could have been discharged. And while I assume the payment will be a DRG payment, it is pretty unlikely that any complication or comorbidity (CC) or major CC (MCC) on the claim will be clinically valid, since the patient is at home and not getting added nursing services or experiencing increasing risk.
I will admit that there are many patients who are quite capable of being discharged from the ED and receiving close follow-up at home, but who are hospitalized because of liability fears or convenience factors – and, during a deadly pandemic, with bed shortages, it would be great to allow some beds to remain open. I hope this program works, but unlike many of the other federal waivers, such as using the hospital auditorium as an inpatient ward or setting up a skilled nursing facility (SNF) without walls, this program cannot be started in a day or a week, and maybe not even in a month. It would help if there was adequate revenue in place to support such a program, with the DRG payment structure, but it will only take one bad outcome to make everyone nervous about continuing.
The clear beneficiaries of this waiver will be those hospitals that have existing programs and can now rely less on grants and their commercial patient population, and those facilities that can now quickly shift to add lower-acuity Medicare patients. For others, they may be forced to watch and learn and plan for the future.
Finally, CMS announced two new condition codes, 90 and 91, for use when a patient gets an expanded access or emergency use authorization service, such as these new medications for COVID.
Check out MLN Matters edition MM12049 for details.
Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic.