Three Key Policies to Advance At-Home Care

Key takeaways:

• The COVID-19 pandemic accelerated the move to home care that has been underway for several years.
• Many Premier members across the continuum are looking to sustain at-home care innovations.
• Premier continues to advocate for policy and regulatory solutions that support our members’ efforts to advance innovative, effective home-based care options.

With recent COVID-19 flexibilities as a springboard, hospitals, health systems and providers across the care continuum have embraced and advanced a home care approach and have tailored programs to meet specific patient and organizational objectives.

This newer avenue of care treat patients in the comfort of their home rather than admitting them to the hospital - and can free up hospital capacity, offer a safe and effective method to appropriately care for certain patients, and unlock the potential for reduced costs and improved outcomes.

Alongside consumer preferences for receiving at-home care, recent studies show this approach is leading to lower rates of mortality and readmissions. Additionally, at-home care can cost up to 38 percent less than care furnished in a facility.[1]

Many Premier members across the continuum are looking to sustain at-home care innovations – aiming to optimize patient engagement, affordability, transformation and patient outcomes.

That’s why Premier is advocating for the following in three key areas:

1 – Hospital-at-Home

In response to a desire to provide better care, reduce readmissions and lower costs, Premier member Mount Sinai Health System explored how to provide care in patients’ homes when appropriate. The health system found patients participating in its hospital-at-home program had:

• An 8.6 percent 30-day readmission rate, compared to 16.1 percent for similar hospitalized patients;
• Fewer ED visits (5.8 percent versus 11.9 percent); and
• A better reported patient experience (67.8 percent versus 45.6 percent).

During the COVID-19 Public Health Emergency (PHE), concerns around acute hospital capacity and patient safety prompted many commercial payers and Medicare to remove restrictions and allow for payment of hospital-at-home services under certain circumstances.

The Acute Hospital Care at Home (AHCAH) program enables providers to effectively monitor and provide at-home care for patients, including remote monitoring capabilities, in-home provider visits, telehealth, medication management, and other care strategies.

Under the program, hospitals can request a waiver of the Medicare Hospital Conditions of Participations (CoPs)[2], requiring nursing services to be provided on premises 24 hours a day and that a registered nurse be immediately available for patient care. Participating hospitals must furnish at least two in-person visits daily and meet certain minimum emergency response times, such as allowing for immediate connection to on-demand virtual care or in-home care within 30 minutes, if needed.

As of July 2022, 110 health systems operating 245 hospitals across 36 states were participating[3] – but the Medicare Hospital-at-Home program will end when the PHE expires unless the Centers for Medicare and Medicaid Services (CMS) acts.

• Premier is supporting the Hospital Inpatient Services Modernization Act introduced in Congress earlier this year. This legislation would extend for two years from the end of the COVID-19 PHE the CMS Acute Hospital Care at Home waiver program that has allowed Premier members and other hospitals to provide certain acute care services to patients from the comfort and safety of their homes.

• To further test the hospital-at-home concept, Premier is encouraging CMS to develop a new Alternative Payment Model (APM) and provide current Accountable Care Organizations (ACOs) the flexibility to implement hospital-at-home programs.

• In alignment with many of Premier’s recommendations, CMS waived other parts of Medicare policy to allow for more virtual care to be furnished in a patient’s home, such as broader telehealth services and allowing for some services to be furnished as audio only. These flexibilities will also expire with the end of the PHE, and CMS should extend these waivers in APMs.

2 – Long-Term Care Pharmacy

With the long-term care (LTC) population expected to nearly double to 27 million by 2050[4], LTC pharmacies are vital to assuring quality of care for patients, whether in LTC facilities, such as nursing homes, assisted living communities — or at home.

But while LTC pharmacies provide important patient care and specialized services in communities across the country, a federal statutory or regulatory definition of LTC pharmacy does not currently exist. Unfortunately, LTC pharmacies are often unintentionally swept up in conflicting, confusing and irrelevant policy proposals that can threaten patient access to essential medications and related pharmacy services.

As a recent example, the absence of a clear LTC pharmacy definition became an issue during the pandemic with respect to the implementation of The Coronavirus Aid, Relief, and Economic Security (CARES) Act Provider Relief Funding.

Without a clear definition, the Health Resources and Services Administration (HRSA) was unable to include LTC pharmacies in their distribution mechanism[5], resulting in LTC pharmacies losing access to virtually all rural distributions, and in many other instances, access to any funds at all.

The Long-Term Care Pharmacy Definition Act of 2021[6] is a longstanding policy priority for Premier and its LTC pharmacy members.

• This legislation would establish a clear statutory definition of LTC pharmacies - driving consistency for all relevant federal agencies as well as Congress. Importantly, lawmakers will have framework to decide when policies should or should not apply to LTC pharmacies.

• The most comprehensive and accurate federal definition of LTC pharmacy services is found inMedicare Part D Long Term Care Guidance[7], which is the starting point for the federal statutory definition legislation.

• In addition to providing a clear definition for lawmakers, this legislation would create a pathway for the growing number of beneficiaries eligible for LTC pharmacy services to receive their care in the home when they choose to do so.

3- Home Infusion

Home infusion care can provide safe, clinically effective care, improve patients' quality of life and reduce healthcare costs. In fact, one study found that home infusion costs produced savings between $1928 and $2974 per treatment course versus infusions done in a medical setting[8].

Congress included provisions in the 21st Century Cures Act and the Bipartisan Budget Act of 2018 to create a professional services benefit for Medicare Part B home infusion drugs[9]. The benefit’s intent was to maintain patient access to home infusion by covering professional services including assessments; education on administration and access device care; monitoring and remote monitoring; coordination with the patient, caregivers and other providers; and nursing visits.

The issue? The Medicare home infusion therapy services benefit still needs improvement to support those beneficiaries who could - and should - receive infusions in the home.

Specifically, CMS’ implementation of the benefit requires a nurse to be physically present in the patient’s home for providers to be reimbursed. The current benefit only acknowledges face-to-face visits from a nurse and fails to account for the extensive clinical and administrative services provided remotely by home infusion clinicians.

As a result, provider participation in Medicare’s home infusion benefit has dropped sharply and beneficiaries have experienced reduced access to home infusion over the last several years[10].

Premier has long advocated for comprehensive home infusion payment reform that recognizes the important services necessary for patients to access high-quality, cost-effective treatment in their preferred setting.

• We’re calling on Congress to pass the Preserving Patient Access to Home Infusion Act[11] expeditiously to ensure vulnerable Medicare patients have continued access to home infusion services.

• The Preserving Patient Access to Home Infusion Act provides clarifications to the 21st Century Cures Act that would ensure Medicare recognizes the full spectrum of professional pharmacy services - including those that minimize the need for face-to-face interactions, which are integral to safe and effective treatment. The legislation will remove the physical presence requirement, ensuring payment regardless of whether a healthcare professional is present in the patient's home.

• The Preserving Patient Access to Home Infusion Act will enable delivery of infused medication in patients' homes, protect those with underlying health conditions from risk of disease, provide access in rural and underserved communities, relieve burden on hospitals, and create savings for patients and taxpayers alike. One analysis estimates this legislation would create $93 million in budgetary savings over 10 years.

With today’s healthcare environment characterized by increased competition and the movement to value, the pandemic demonstrated the value of at-home care and the ability of healthcare providers to furnish care remotely.

Looking ahead, the success of at-home care is contingent upon regulatory clarity and appropriate financial reimbursement. Absent these two keys elements working in tandem, we run the risk of losing out on the potential cost, patient experience and outcomes benefits this care setting can bring.

Now and for the future, Premier will continue to advocate for policy and regulatory solutions that support our members’ efforts to advance innovative, effective care delivery options – including those provided at home.

Learn More:

• Check out the Congressional Briefing — Ensuring Long-Term Care Patients’ Access to Essential Medications.
• See how Premier’s Continuum of Care services are driving value for members.
• Learn how Premier’s Public Affairs team works to shape federal laws and regulations to align with members’ efforts to deliver high-quality and cost-effective care.

[1] https://www.acpjournals.org/doi/10.7326/M19-0600.

[2] https://www.aana.com/advocacy/federal-government-affairs/medicare-cops-and-interpretive-guidelines.

[3] https://qualitynet.cms.gov/acute-hospital-care-at-home/resources.

[4] https://www.transparencymarketresearch.com/long-term-care-services-market.html.

[5] https://seniorcarepharmacies.org/hhs-fails-to-address-pandemic-relief-for-long-term-care-pharmacies-2.

[6] https://www.congress.gov/bill/117th-congress/house-bill/5632/all-info?r=9&s=1.

[7] https://www.cms.gov/Medicare/P... Coverage/PrescriptionDrugCovContra/downloads/LTCGuidance.pdf.

[8] https://pubmed.ncbi.nlm.nih.gov/28668202.

[9] https://www.congress.gov/bill/115th-congress/house-bill/1892/text.

[10] https://www.cms.gov/files/document/hit-monitoring-report-january-2022.pdf.

[11] https://www.congress.gov/bill/117th-congress/house-bill/5067/text?r=5&s=1.

[12] https://nhia.org/wp-content/uploads/2020/03/The_Moran_Company_Home_Infusion_Policies_Score-Jan.-2020.pdf.