Hospital at Home: Paying for What It's Worth

ABSTRACT

Am J Manag Care. 2021;27(9)369-371. https//doi.org/10.37765/ajmc.2021.88739 _____ Takeaway Points A framework centered around cost, quality, and equity is essential to define the value of hospital-at-home programs. * Validated disease-specific tools should be consistently used to measure process metrics, outcome metrics, quality-of-life measures, and caregiver satisfaction measures. * Equity-focused process metrics, care utilization measures, and risk-adjusted outcome metrics should be reported. * Total costs of care for hospital-at-home programs should be consistently measured through a time-driven activity-based costing method. * Personal, societal, technical, and allocative value should be considered when determining the value of hospital-at-home programs. _____ In recent years, home health care has grown to 3% of overall US health care spending.1 Investment in home health care delivery including telemedicine grew considerably during the COVID-19 pandemic.2 One area that has lagged in terms of growth has been the hospital-at-home model. For home health agencies (different from hospital-at-home programs, which provide more acute care services), CMS uses a more comprehensive Home Health Quality Reporting process to assess risk-adjusted process measures, outcomes measures, occurrences of adverse events, utilization of care measures, and cost measures.9 After the COVID-19 pandemic, similar reporting processes should be implemented for measuring the quality and outcomes of hospital-at-home programs. Because hospital-at-home programs share features of both inpatient hospital admissions and home health agencies, they are uniquely positioned to both treat the patient acutely and improve the living conditions and resources that led to the acute illness. The American Heart Association's Get With the Guidelines – Heart Failure, an in-hospital program, describes a comprehensive, robust set of quality measurements including process and outcome measurements for heart failure management.11 Process metrics include assessment of left ventricular ejection fraction, adherence to guideline-recommended medical therapy at discharge, and scheduled follow-up;process metrics correlate well to high-quality heart failure care.12 Outcome metrics include 30-day mortality and 30-day readmission rates.12 Although hospital-at-home programs have been associated with lower costs, these cost reductions are mostly due to reduced length of hospitalization,13 number of consultations,14 and clinical testing.13 It is yet unclear if the reduction in services utilized also leads to a reduction in value for the patient—either through fewer completed process metrics or significantly increased caregiver burden. Of 34 studies included in a meta-analysis comparing the costs of hospital at home with those of hospitalizations, 32 studies found hospital at home to cost less.3 For example, in a recent randomized controlled trial evaluating patients treated in a hospital-at-home program compared with those treated in a traditional hospital, the risk-adjusted cost reduction of home care management was 19%.15 In this trial, costs were calculated by summing the costs of labor, equipment, medications, laboratory tests, imaging tests, and transport during the period of hospitalization.15 In hospital-at-home models, cost savings are thought to be achieved due to reduced length of hospitalization,13 decreased number of consultations,14 reduced nursing labor costs,15 and decreased clinical testing.13 However, no uniform method exists to track and assess costs,16 and there is worry that the costs of hospital-at-home programs are underestimated.17 To fill this gap, these programs should report and analyze the total costs of care—including costs incurred by patients and their caregivers—rather than simply the reimbursement rates for care.