Mass General Brigham sees hospital-at-home care as a big part of its long-term future. In the short term, the nonprofit health system's plan depends on a favorable ruling from the Centers for Medicare and Medicaid Services.
The Boston-based provider says it is on track to shift 10% of inpatient care to hospital-at-home—through which acute care is delivered in-home and virtually and patients are connected to remote monitoring—within five years. In the coming weeks, Mass General Brigham anticipates word from CMS about regulatory waivers that would enable that expansion by approving Medicare reimbursements for these services that match payments for inpatient care.
Mass General Brigham needs to create a hospital-at-home program that it can sustain regardless of what CMS decides, said Dr. Stephen Dorner, chief clinical and innovation officer of the health system's hospital-at-home programs. “We have to build a business model that can deliver the same care that’s necessary within the home, while fulfilling the need to function as a business,” he said.
Mass General Brigham announced last year it was making a big bet on hospital-at-home. Brigham and Women’s Hospital and Massachusetts General Hospital in Boston already offer hospital-at-home services for what amounts to 30 beds per day. The health system wants to increase that to 200 beds per day within a few years, starting with three Massachusetts hospitals: Newton Wellesley Hospital; Salem Hospital; and Brigham and Women’s Faulkner Hospital in Jamaica Plain.
Mass General Brigham would not estimate how much its hospital-at-home expansion will cost or outline its profit expectations. The current program is “breaking even,” said Heather O’Sullivan, president of Mass General Brigham Healthcare at Home.
Escalating demand from an aging population with greater healthcare needs is driving the initiative. The hospital-at-home program is one component of a larger strategy to meet that demand. For instance, Mass General Brigham broke ground last year on a $2 billion, 482-bed expansion of its flagship Massachusetts General Hospital campus in Boston that will serve cancer and cardiac patients.
The hospital-at-home gambit serves another purpose. Mass General Brigham suffered a $2 billion loss last year that highlighted the need to cut costs, O’Sullivan said. Treating patients at home is 38% less costly than inpatient care, the health system reported in the Annals of Internal Medicine in 2018. Research published in 2021 found that readmissions for hospital-at-home patients occurred at roughly half the rate as for patients treated inside hospitals.
Mass General Brigham was an early adopter of hospital-at-home and operates one of the largest programs in the country. In 2016, Brigham and Women’s Hospital and Massachusetts General Hospital launched hospital-at-home pilots. Mass General Brigham scaled up the programs during the COVID-19 pandemic when CMS created the Acute Care at Home waiver pilot. The program—set to expire at the end of 2024—reimburses at the same rate whether patients get treated at home or in hospitals.
The health system has an opportunity to blaze the way for other providers to follow, O'Sullivan said. “It is our imperative as a system to build the playbook for other hospitals or even systems that don’t have the support or encouragement that [Mass General Brigham] has placed on this,” she said.
Medicare reimbursement remains the wild card. There are no guarantees CMS will continue to reimburse hospital-at-home services at parity with inpatient care. CMS is still collecting data from the more than 400 hospitals in the waiver program to determine whether Medicare will continue the current payment policy or devise a new one. Whatever CMS decides is likely to provide a roadmap for private health insurance companies.
Scaling hospital-at-home to 10% of patient volume may be a way for hospitals to prove return on investment and to make the case for generous reimbursements, said Shannon Germain Farraher, senior healthcare analyst at research and advisory company Forrester. To achieve good results, however, health systems need appropriate infrastructure to enable coordination among staff members, vendors and a plethora of other partners, ranging from social workers to spiritual advisors, she said.
“If you think about what can be provided in the hospital, you have to be able to provide that at home,” Farraher said. “It does include understanding your patient population, where they live and the community resource they use.”