Monitoring acute heart patients at home linked to considerable cost savings
Patients monitored at home rather than in the hospital for acute conditions may be associated with cost savings and higher patient satisfaction scores, according to a new study released in September by the Centers for Medicare and Medicaid Services (CMS). Pulmonology was by far the biggest user of the program in the time period due to respiratory issues from COVID-19, but cardiology was No. 2 for program utilization in the areas of myocardial infarction and heart failure.
CMS was not a big fan of in-home care for acute care patients prior to the pandemic. However, with hospitals at capacity in late 2020 due to the pandemic and with the COVID-19 Public Health Emergency (PHE) in place to quickly change how care was delivered, CMS created the Acute Hospital Care at Home (AHCAH) initiative. This enabled hospitals to divert care of less serious cases to a "hospital at home" model so they were not tying up beds and resources in the hospital that more acute cases needed. While this can require some additional logistics and equipment, CMS said the study found cost savings. The positive report means CMS may choose to extend these types of programs in the future to include more patients.
In addition, as CMS looks to convert most of its payment models from fee-for-service to value-based care by 2030, the positive cost savings from this program will likely influence CMS and hospital decisions in the next few years.
"The data analyzed indicate that Medicare spending for services furnished in 30-day post-discharge period were significantly lower across more than half of the top 25 clinical conditions treated and diagnosis-related groups (MS-DRGs) in the AHCAH group," the CMS report stated in its summary.
The timeframe of the study was between November 2020 through January 2024, and the analysis attempted to show a comparison between AHCAH at-home care compared to brick-and-mortar inpatient care.
The most common MS-DRGs and major diagnostic categories (MDCs) treated through the AHCAH initiative included respiratory (36%), circulatory (16%), renal (16%), and infectious diseases (12%), for a total of 25 “top MS-DRGs” among patients served by hospitals with approved AHCAH waivers.
Many of the results from this study appear consistent with the intentions of AHCAH, including the delivery of safe, quality inpatient care in the home and alleviation of strains on brick-and-mortar hospital capacity for appropriately selected patients," CMS concluded in the report.
However, the AHCAH initiative was not established for controlled comparisons or as a method to evaluate the care delivery or payment model, so the agency said it is constrained in drawing definitive conclusions about the impact of the AHCAH initiative.
Participation in the AHCAH hospital-at-home program
As of July 24, 2024, CMS had approved 54 Tier 1 CMS Certification Numbers (CCNs), or acute care hospitals/facilities, and 278 Tier 2 CCNs for a total of 332 participating hospitals across 38 states. CMS said 93% of patients admitted to AHCAH-approved hospitals are in urban areas.
Diagnosis selection criteria for cardiovascular issues for the program includes newly diagnosed congestive heart failure (CHF), need for continuous diuretic infusion, decompensated congestive heart failure, deep venous thrombosis (DVT), and pulmonary embolism (PE). Other non-cardiac areas where patients can be monitored remotely include infectious disease, acute kidney injury (AKI), acute asthma exacerbation, acute chronic obstructive pulmonary disease (COPD) exacerbation, hyperosmolar hyperglycemic states, and diabetic ketoacidosis (DKA).
CMS found AHCAH beneficiaries are generally (but not universally) less clinically complex than patients in the comparison group. Cardiac patients in the highest risk DRG groups discharged for home monitoring included those with acute myocardial infarction with MCC, and heart failure and shock with MCC.
CMS said certain diagnoses may be easier to treat at home if there is less clinical complexity. However, in some cases, hospitals may make strategic investments in operational capabilities to treat more complex patients in the home, particularly if the hospital has specialized clinical expertise and operational capabilities to do so.
Patients need to have a willingness to engage and actively participate in the care plan, and accept virtual and in-home visits multiple times per day. They also need to be English-speaking, or other languages that a hospital can accommodate, and be able to operate necessary technology either independently or with assistance from an available caregiver/support person. In addition, a patient needs to have a home environment conducive for at-home care; this includes one with running water, climate control, refrigeration, space for medical equipment and smartphone and internet availability. Patients should also be close enough for timely transport to a hospital in case of an emergency.
This analysis also found that the hospital patient inclusion/exclusion criteria made by hospitals and patients impacted the demographic makeup of the AHCAH population. Patients who participated in at-home care were significantly more likely to be white, live in an urban location and not receive Medicaid or low-income subsidies. Beneficiaries currently served by hospitals with AHCAH waivers are also located in predominantly urban areas with a significant number of academic hospitals participating in the initiative, which likely also influenced patient demographics, CMS said.
Most common MS-DRGs and MDCs treated through the AHCAH initiative
The most common MS-DRGs and MDCs treated through the AHCAH initiative at the MDC level conditions included a range of respiratory (36%), circulatory (16%), renal (16%), and infectious diseases (12%).
Circulatory disorders (MDC 05) made up 16% of claims, which included 2,713 patients and totaling $31 million in CMS payments.
Leading the top 10 AHCAH DRG by number of claims was DRG 291 for heart failure with shock and MCC. This DRG made up 12% of total episodes in the program and total CMS paid for care of these 1,916 patients was $19.5 million.
CMS said comparisons were relatively similar for patient 30-day readmissions of patients heart failure with shock in both AHCAH inpatients and their brick-and-mortar counterparts. A comparison of 30-day mortality showed a much higher rate for patients that were kept at the hospital, but CMS notes this is likely due to much higher severity of disease compared to patients who were deemed stable enough to have home monitoring.
The average cost of care comparison for heart failure with shock and MCC for at-home monitoring was $7,328, and in-hospital was $7,706, a difference of $378. Multiplied by the number of patients included in the group during the study period, this was a savings to CMS of more than $724,000.
CMS found a cost savings of at-home care for acute myocardial infarction with MCC as well. It was among 13 DRGs that had significantly lower at-home care costs, $8,566 vs. $11,690, a $3,124 savings per patient.
The study overall found AHCAH beneficiaries accounted for lower Medicare spending during the 30-days post-discharge period. Additionally, while beneficiaries treated under the AHCAH initiative received the same types of services as patients in the brick-and-mortar facility, AHCAH beneficiaries used fewer of those same services. The post-discharge care and services utilized suggest that hospitals may incur lower costs over time for the provision of care to AHCAH patients, CMS concluded.
Hospital service utilization of cardiology services was 8% lower with at-home care compared to in-hospital care.
In interviews with caregivers, CMS said that in-home care allowed them to be more involved in the care process, and they themselves felt more comfortable and less stressed when their loved ones were cared for at home. Finally, patients, family members and caregivers described the initial orientation to AHCAH, and ongoing education received from clinical staff, to be a critical component supporting the care transition from hospital to home.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com