Mass General Brigham started its hospital-at-home efforts nearly a decade ago, well before the waiver existed. Even so, the waiver spurred adoption and utilization to new heights, allowing the health system to include Medicare and Medicaid patients in the program.
According to Dorner, the health system's hospital-at-home program has cared for more than 5,000 patients since its inception. However, the uncertainty of the waiver's future and the short-term extensions make it hard for the organization to plan for the future of the program, which, according to Dorner's account, has been highly beneficial to patients.
"As I've talked to other health systems and hospitals around how they're preparing for these plans and what they've built, there's a lot of fear and uncertainty about [the waiver being eliminated] because we know that it would mean changing the way that we're delivering care today to something else," he said. "We know that means that we're going to lose potentially the benefits that we know are delivered through this care model today."
Jennifer Holloman, senior associate director of policy at AHA, echoed this, adding that hospital-at-home programs require significant infrastructure and resources.
"There are things like remote patient monitoring equipment that hospitals need to acquire, facilitating meal delivery services, as well as just the general staffing and workflow redesign that simply providing a few months extension or a one-year extension doesn't provide [the time for]," she said.
"Having a short-term extension really does not provide the bandwidth or on-ramp for hospitals to be able to develop these types of programs," she continued.
Additionally, the lack of federal support for the program could result in less support from commercial health plans. Without a definite return on investment, Bales said that health systems will be less likely to invest in hospital-at-home programs, hampering the growing adoption.
"[Hospitals are] going to invest in the replacement of their metal equipment," he said. "They're going to invest in what is it they need to do in order to keep their EHRs up and running to keep the hospital staff. And so, subsequently, there will likely be a stall in the migration to the home setting until the reimbursement balances back out."
Not only that, but the short-term extensions are exacerbating concerns about capacity management. If the waiver expires in September, hospitals will be expected to move their patients back into their brick-and-mortar facilities immediately until they receive further guidance from the government.
"We will make plans to bring those patients back to the hospital in compliance with the CMS guidance, but we don't have a ready way for us to just create additional capacity in short order," Dorner said. "That's exactly why this waiver was created in the first place -- in recognition of the fact that hospitals don't have adequate capacity and that this is a critical release valve to those hospitals to meet patient care needs. And it would be a shame for it to go away."
Amid the unknowns about the waiver's future, Mass General's strategy is to continue focusing on its overarching plan to provide a home-based complement to in-person care services where necessary.
"We'll look at that broad continuum opportunity and where we can intervene if there's compression at any point along that continuum, like a restriction of the waiver's conditions of participation," Dorner said. "We know that the further you can intervene upstream, the better you can try to intervene upon utilization patterns and improve overall health for patients. And so, we've long been working in that space, and we'll continue to do so."
However, it will also become increasingly crucial for hospital-at-home stakeholders to advocate for the waiver.
"There's certainly a big piece of the advocacy side here as well, and educating members of Congress about the value that this program provides and highlighting the patient stories, success stories...that's how Congress learns more, but it's also helpful and as they deliberate to connect that back to the impact it's having in each of their congressional districts," said Rachel Jenkins, senior associate director of federal relations at AHA.
The hospital-at-home waiver is among many federal health agencies and programs in upheaval as the Trump administration solidifies its agenda. Still, the bipartisan support for hospital-at-home, combined with provider and patient advocacy for the waiver, could help embed the model further into the healthcare delivery system, which Dorner sees as a net positive for the industry and Americans' health.
"I think at a time that there's great interest in trying to find beneficial ways that bolster the economy and improve quality of life for Americans, [hospital-at-home] is a very clear win-win opportunity sitting in front of us," said Dorner.