HR 4313 — Hospital Inpatient Services Modernization Act

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

 In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows.

 Changes in Existing Law Made by the Bill, as Reported

 In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italics, and existing law in which no 
change is proposed is shown in roman):

 SOCIAL SECURITY ACT

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TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED

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Part E--Miscellaneous Provisions

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SEC. 1866G. EXTENSION OF ACUTE HOSPITAL CARE AT HOME INITIATIVE.

 (a) In General.--
 (1) Extension.--With respect to inpatient hospital 
 admissions occurring during the period beginning on the 
 first day after the end of the emergency period 
 described in section 1135(g)(1)(B) and ending on 
 September 30, [2025] 2030, the Secretary of Health and 
 Human Services shall grant waivers and flexibilities 
 (as described in paragraph (2)) to an individual 
 hospital that submits a request for such waivers and 
 flexibilities and meets specified criteria (as 
 described in paragraph (3)) in order to participate in 
 the Acute Hospital Care at Home initiative of the 
 Secretary.
 (2) Acute hospital care at home waivers and 
 flexibilities.--For the purposes of paragraph (1), the 
 waivers and flexibilities described in this paragraph 
 are the following waivers and flexibilities that were 
 made available to individual hospitals under the Acute 
 Hospital Care at Home initiative of the Secretary 
 during the emergency period described in section 
 1135(g)(1)(B):
 (A) Subject to paragraph (3)(D), waiver of 
 the requirements to provide 24-hour nursing 
 services on premises and for the immediate 
 availability of a registered nurse under 
 section 482.23(b) of title 42, Code of Federal 
 Regulations (or any successor regulation), and 
 the waivers of the physical environment and 
 Life Safety Code requirements under section 
 482.41 of title 42, Code of Federal Regulations 
 (or any successor regulation).
 (B) Flexibility to allow a hospital to 
 furnish inpatient services, including routine 
 services, outside the hospital under 
 arrangements, as described in Medicare Program: 
 Hospital Outpatient Prospective Payment and 
 Ambulatory Surgical Center Payment Systems and 
 Quality Reporting Programs; Organ Acquisition; 
 Rural Emergency Hospitals: Payment Policies, 
 Conditions of Participation, Provider 
 Enrollment, Physician Self-Referral; New 
 Service Category for Hospital Outpatient 
 Department Prior Authorization Process; Overall 
 Hospital Quality Star Rating; COVID-19 (87 Fed. 
 Reg. 71748 et seq.).
 (C) Waiver of the telehealth requirements 
 under clause (i) of section 1834(m)(4)(C), as 
 amended by section 4113(a) of the Health 
 Extenders, Improving Access to Medicare, 
 Medicaid, and CHIP, and Strengthening Public 
 Health Act of 2022, such that the originating 
 sites described in clause (ii) of such section 
 shall include the home or temporary residence 
 of the individual.
 (D) Other waivers and flexibilities that, as 
 of the date of enactment of this section, were 
 in place for such initiative during such 
 emergency period.
 (3) Specified criteria.--For purposes of paragraph 
 (1), the specified criteria for granting such waivers 
 and flexibilities to individual hospitals are:
 (A) The hospital shall indicate to the 
 Secretary the criteria it would use to ensure 
 that hospital services be furnished only to an 
 individual who requires an inpatient level of 
 care, and shall require that a physician 
 document in the medical record of each such 
 individual that the individual meets such 
 criteria.
 (B) The hospital and any other entities 
 providing services under arrangements with the 
 hospital shall ensure that the standard of care 
 to treat an individual at home is the same as 
 the standard of care to treat such individual 
 as an inpatient of the hospital.
 (C) The hospital shall ensure that an 
 individual is only eligible for services under 
 paragraph (1) if the individual is a hospital 
 inpatient or is a patient of the hospital's 
 emergency department for whom the hospital 
 determines that an inpatient level of care is 
 required (as described in subparagraph (A)).
 (D) The hospital shall meet all patient 
 safety standards determined appropriate by the 
 Secretary, in addition to those that otherwise 
 apply to the hospital, except those for which 
 the waivers and flexibilities under this 
 subsection apply.
 (E) The hospital shall provide to the 
 Secretary, at a time, form and manner 
 determined by the Secretary, any data and 
 information the Secretary determines necessary 
 to do the following:
 (i) Monitor the quality of care 
 furnished, and to the extent 
 practicable, ensure the safety of 
 individuals and analyze costs of such 
 care.
 (ii) Undertake [the study described 
 in subsection (b)] the studies 
 described in subsections (b) and (c).
 The Secretary may require that such data and 
 information be submitted through a hospital's 
 cost report, through such survey instruments as 
 the Secretary may develop, through medical 
 record information, or through such other means 
 as the Secretary determines appropriate.
 (F) The hospital meets such other 
 requirements and conditions as the Secretary 
 determines appropriate.
 (4) Termination.--The Secretary may terminate a 
 hospital from participation in such initiative (and the 
 waivers and flexibilities applicable to such hospital) 
 if the Secretary determines that the hospital no longer 
 meets the criteria described in paragraph (3).
 (b) [Study] Initial Study and Report.--
 (1) In general.--The Secretary shall conduct a study 
 to--
 (A) analyze, to the extent practicable, the 
 criteria established by hospitals under the 
 Acute Hospital Care at Home initiative of the 
 Secretary to determine which individuals may be 
 furnished services under such initiative; and
 (B) analyze and compare, to the extent 
 practicable--
 (i) quality of care furnished to 
 individuals with similar conditions and 
 characteristics in the inpatient 
 setting and through the Acute Hospital 
 Care at Home initiative, including 
 health outcomes, hospital readmission 
 rates, hospital mortality rates, length 
 of stay, infection rates, and patient 
 experience of care;
 (ii) clinical conditions treated and 
 diagnosis-related groups of discharges 
 from the inpatient setting and under 
 the Acute Hospital Care at Home 
 initiative;
 (iii) costs incurred by furnishing 
 care in the inpatient setting and 
 through the Acute Hospital Care at Home 
 initiative;
 (iv) the quantity, mix and intensity 
 of such services (such as in-person 
 visits and virtual contacts with 
 patients) furnished in the Acute 
 Hospital Care at Home initiative and 
 furnished in the inpatient setting; and
 (v) socioeconomic information on 
 beneficiaries treated under the 
 initiative, including racial and ethnic 
 data, income, and whether such 
 beneficiaries are dually eligible for 
 benefits under this title and title 
 XIX.
 (2) Report.--Not later than September 30, 2024, the 
 Secretary of Health and Human Services shall post on a 
 website of the Centers for Medicare & Medicaid Services 
 a report on the study conducted under paragraph (1).
 (3) Funding.--In addition to amounts otherwise 
 available, there is appropriated to the Centers for 
 Medicare & Medicaid Services Program Management Account 
 for fiscal year 2023, out of any amounts in the 
 Treasury not otherwise appropriated, $5,000,000, to 
 remain available until expended, for purposes of 
 carrying out this subsection.
 (c) Subsequent Study and Report.--
 (1) In general.--Not later than September 30, 2028, 
 the Secretary shall conduct a study to--
 (A) analyze, to the extent practicable, the 
 criteria established by hospitals under the 
 Acute Hospital Care at Home initiative to 
 determine which individuals may be furnished 
 services under such initiative; and
 (B) analyze and compare (both within and 
 between hospitals participating in the 
 initiative, and relative to comparable 
 hospitals that do not participate in the 
 initiative, for relevant parameters such as 
 diagnosis-related groups)--
 (i) quality of care furnished to 
 individuals with similar conditions and 
 characteristics in the inpatient 
 setting and through the Acute Hospital 
 Care at Home initiative, including 
 health outcomes, hospital readmission 
 rates (including readmissions both 
 within and beyond 30 days post-
 discharge), hospital mortality rates, 
 length of stay, infection rates, 
 composition of care team (including the 
 types of labor used, such as contracted 
 labor), the ratio of nursing staff, 
 transfers from the hospital to the 
 home, transfers from the home to the 
 hospital (including the timing, 
 frequency, and causes of such 
 transfers), transfers and discharges to 
 post-acute care settings (including the 
 timing, frequency, and causes of such 
 transfers and discharges), and patient 
 and caregiver experience of care;
 (ii) clinical conditions treated and 
 diagnosis-related groups of discharges 
 from inpatient settings relative to 
 discharges from the Acute Hospital Care 
 at Home initiative;
 (iii) costs incurred by the hospital 
 for furnishing care in inpatient 
 settings relative to costs incurred by 
 the hospital for furnishing care 
 through the Acute Hospital Care at Home 
 initiative, including costs relating to 
 staffing, equipment, food, 
 prescriptions, and other services, as 
 determined by the Secretary;
 (iv) the quantity, mix, and intensity 
 of services (such as in-person visits 
 and virtual contacts with patients and 
 the intensity of such services) 
 furnished in inpatient settings 
 relative to the Acute Hospital Care at 
 Home initiative, and, to the extent 
 practicable, the nature and extent of 
 family or caregiver involvement;
 (v) socioeconomic information on 
 individuals treated in comparable 
 inpatient settings relative to the 
 initiative, including racial and ethnic 
 data, income, housing, geographic 
 proximity to the brick-and-mortar 
 facility and whether such individuals 
 are dually eligible for benefits under 
 this title and title XIX; and
 (vi) the quality of care, outcomes, 
 costs, quantity and intensity of 
 services, and other relevant metrics 
 between individuals who entered into 
 the Acute Hospital Care at Home 
 initiative directly from an emergency 
 department compared with individuals 
 who entered into the Acute Hospital 
 Care at Home initiative directly from 
 an existing inpatient stay in a 
 hospital.
 (2) Selection bias.--In conducting the study under 
 paragraph (1), the Secretary shall, to the extent 
 practicable, analyze and compare individuals who 
 participate and do not participate in the initiative 
 controlling for selection bias or other factors that 
 may impact the reliability of data.
 (3) Report.--Not later than September 30, 2028, the 
 Secretary of Health and Human Services shall submit to 
 the Committee on Ways and Means of the House of 
 Representatives and the Committee on Finance of the 
 Senate a report on the study conducted under paragraph 
 (1).
 [(c)] (d) Implementation.--Notwithstanding any other 
provision of law, the Secretary may implement this section by 
program instruction or otherwise.
 [(d)] (e) Publicly Available Information.--The Secretary 
shall, as feasible, make the information collected under 
subsections (a)(3)(E) and (b)(1) available on the Medicare.gov 
internet website (or a successor website).

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 VII. SUPPLEMENTAL VIEWS

 H.R. 4313 would extend the Acute Hospital Care at Home 
(AHCaH) waivers for five additional years, through December 31, 
2030. It would also require the Secretary to conduct a follow-
up study, analyzing aspects of AHCaH including, but not limited 
to, inclusion criteria for AHCaH across hospitals, quality of 
care, costs of furnishing such care, socioeconomic information 
of individuals treated through AHCaH, and point of entry into 
AHCaH (either directly from an emergency department or from an 
existing inpatient stay in a hospital).
 While Democrats broadly support extending the HaH program 
while we gather more data, recent Republican actions are 
jeopardizing the ability of hospitals to continue to serve many 
communities. Just months ago, Republicans passed H.R. 1, which 
cut more than $1.4 trillion from the health care system and 
would cause more than 15 million people to lose insurance 
coverage. These cuts and resultant coverage loss will strain 
the health system and lead to more uncompensated and forgone 
care. The University of North Carolina's Cecil G. Sheps Center 
found that more than 300 rural hospitals are at risk because of 
the policies in H.R. 1.\1\ Additionally, the Republicans' law 
increases the deficit by trillions of dollars, triggering 
additional automatic Medicare cuts under the statutory Pay-As-
You-Go Act (PAYGO). These cuts will reduce payments to Medicare 
providers--including hospitals--by over $500 billion, or four 
percent, all in service of a giant tax giveaway to the richest 
1 percent of Americans.\2\
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 \1\https://www.wral.com/lifestyle/health/nc-rural-hospitals-risk-
closure-one-big-beautiful-bill-act-june-2025/.
 \2\https://www.cbo.gov/system/files/2025-08/61659-SPAYGO.pdf.
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 Democrats offered several amendments to mitigate the 
Republican assault on health care. First, Congressman Horsford 
(D-NV) offered an amendment to permanently extend the tax 
credits that help make insurance coverage affordable for those 
who purchase their own insurance. On average, low-and-middle 
income Americans will see their premiums increase by 93 
percent, and many more will pay thousands more for health care 
due to Republican choices.\3\ Republicans ruled this amendment 
out of order on a procedural vote. Then, Congressman Thompson 
(D-CA) offered an amendment to extend these tax credits for 
just one year. Even though Committee Republicans purport to 
support this modest approach, they voted to block its 
consideration.
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 \3\https://americanscovered.org/about/about-the-issue/.
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 Rep. Chu (D-CA) offered an amendment to prevent over $500 
billion in Medicare cuts over the next ten years, which are 
triggered by the Republicans' tax breaks for the wealthiest. 
The Republicans ruled this amendment out of order as well. Rep. 
Schneider offered an amendment to continue Medicare 
beneficiaries' access to the same scientific and evidence-based 
vaccines as they had in 2024, including the no cost-sharing 
terms. Under the Trump Administration, evidence-based vaccines 
that have saved millions of lives are under attack. Secretary 
Kennedy at HHS has upended the Advisory Committee on 
Immunization Practices (ACIP) in favor of pseudo-science, 
threatening the lives of Americans who rely on vaccines to 
prevent diseases and potentially increasing costs for those who 
access vaccines no longer recommended by ACIP despite sound 
scientific evidence. The Republicans once again blocked this 
amendment from consideration.
Hospital at Home Background and Considerations
 Hospital at Home (HaH) refers to a specific care model 
developed by Johns Hopkins University in which a health care 
organization provides inpatient-level care to patients in their 
homes.\4\ Several other countries, as well as some U.S. 
hospitals, have implemented versions of a HaH program; however, 
broader uptake in the U.S. was limited until the COVID-19 
pandemic.\5\
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 \4\Hospital at Home, Johns Hopkins Medicine (last visited on Mar. 
8, 2024), https://www.johnshopkinssolutions.com/solution/hospital-at-
home/.
 \5\Sarah Klein, ``Hospital at Home'' Programs Improve Outcomes, 
Lower Costs But Face Resistance from Providers and Payers, The 
Commonwealth Fund (last visited on Mar. 8, 2024), https://
www.commonwealthfund.org/publications/newsletter-article/hospital-home-
programs-
improve-outcomes-lower-costs-face-resistance.
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 As part of the COVID-19 Public Health Emergency waivers CMS 
implemented in March 2020, CMS began the ``Hospitals Without 
Walls'' initiative, which provided broad regulatory flexibility 
to allow health systems and hospitals to provide hospital-level 
care to patients beyond their existing walls.\6\ Using waiver 
authorities granted to CMS under section 1135 of the Social 
Security Act (the pandemic waivers), hospitals could transfer 
patients to non-hospital facilities while still receiving 
hospital payments under Medicare.\7\\8\ This waiver allowed 
hospitals to reserve inpatient beds for the most critically ill 
patients and expand capacity during the initial COVID-19 
response.
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 \6\Additional Background: Sweeping Regulatory Changes to Help U.S. 
Healthcare System Address COVID-19 Patient Surge, Centers for Medicare 
and Medicaid Services (Mar. 30, 2020), https://www.cms.gov/newsroom/
fact-sheets/additional-backgroundsweeping-
regulatory-changes-help-us-healthcare-system-address-covid-19-patient.
 \7\CMS Announces Comprehensive Strategy to Enhance Hospital 
Capacity Amid COVID-19 Surge, Centers for Medicare and Medicaid 
Services (Nov. 25, 2020), https://www.cms.gov/newsroom/press-releases/
cms-announces-comprehensive-strategy-enhance-hospital-capacity-amid-
covid-19-surge.
 \8\Additional Background: Sweeping Regulatory Changes to Help U.S. 
Healthcare System Address COVID-19 Patient Surge, Centers for Medicare 
and Medicaid Services (Mar. 30, 2020), https://www.cms.gov/newsroom/
fact-sheets/additional-backgroundsweeping-
regulatory-changes-help-us-healthcare-system-address-covid-19-patient.
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 In November 2020, CMS launched the Acute Hospital Care at 
Home (AHCaH) initiative, which built off Hospitals Without 
Walls. Under AHCaH, CMS allows certain Medicare-certified 
hospitals to request to waive Sec. 482.23(b) and (b)(1) of the 
Hospital Conditions of Participation (CoP), which require 24/7 
on-premises nursing services and a registered nurse (RN) to be 
immediately available to care for a patient.\9\ In addition, 
the Secretary waived hospital physical environment and ``Life 
Safety Code'' requirements for delivering care in patients' 
homes.\10\
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 \9\Acute Hospital Care at Home, CMS QualityNet (last visited on 
Mar. 8, 2024), https://qualitynet.cms.gov/acute-hospital-care-at-home.
 \10\Acute Hospital Care at Home Data Release Fact Sheet, Centers 
for Medicare and Medicaid Services (Jan. 16, 2024), https://
www.cms.gov/newsroom/fact-sheets/acute-hospital-care-home-data-release-
fact-sheet.
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 Under this model, each hospital determines the clinical 
conditions and criteria for ACHaH services. Medicare's other 
CoPs remain unchanged, and CMS performs a review of off-site 
hospital operations and processes to ensure that each 
requesting hospital could satisfy them in the home environment. 
Hospitals must also have two in-person daily clinical visits by 
a nurse or paramedic, ensure 24/7 contact between patients and 
the hospital, and be able to reach the patient at home within 
30 minutes. Approved hospitals receive full payment under the 
inpatient prospective payment system (IPPS) through Medicare 
Severity-Diagnosis Related Groups (MS-DRG) as well as 
applicable add-on payments.\11\
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 \11\Acute Care Delivery at Home, Assistant Secretary for 
Preparedness and Response (Apr. 2021), https://
files.asprtracie.hhs.gov/documents/aspr-tracie-acute-care-delivery-at-
home-tip-sheet-.pdf.
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 Hospitals participating in AHCaH must submit waivers for 
each individual entity with a CMS Certification Number (CCN) 
rather than for a whole hospital system.\12\ CMS categorizes 
AHCaH waiver requests based on prior hospital experience with 
home acute hospital services.\13\ Hospitals previously 
providing care to 25 or more patients go through an expedited 
process to allow experienced hospitals to rapidly expand care, 
while hospitals previously providing care to 25 or fewer 
patients (or who never previously furnished care in the home) 
must submit a more detailed waiver request demonstrating home 
patients will receive the same level of care as patients in 
traditional inpatient units. Hospitals approved via the 
expedited waiver pathway are required to submit monitoring data 
monthly. Similarly, hospitals approved via the detailed waiver 
pathway are required to submit monitoring data weekly. 
Monitoring data includes information on patient volume, 
unanticipated mortality during an acute episode of care, 
escalation rate (i.e., discharges involving transfer from acute 
hospital care at home to traditional inpatient setting), 
attestation that a hospital's acute hospital care at home 
safety committee reviewed the reported metrics, and the patient 
list.\14\
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 \12\Acute Hospital Care at Home, CMS QualityNet (last visited on 
Mar. 8, 2024), https://qualitynet.cms.gov/acute-hospital-care-at-home.
 \13\Id.
 \14\Id.
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 In December 2022, Congress enacted H.R. 2716, Consolidated 
Appropriations Act for Fiscal Year 2023 (CAA, 2023), which 
extended flexibilities granted under the AHCaH waiver program 
through December 31, 2024.\15\ The CAA, 2023, also requires 
hospitals to submit additional data the Secretary determines 
necessary to monitor quality of care, safety, and cost. CMS 
must release a report analyzing AHCaH utilization, quality, 
outcomes, and cost by September 30, 2024.
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 \15\The Consolidated Appropriates Act, 2023, 42 U.S.C. 
Sec. 1395(cc-7) (2023).
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 Policy considerations. Broadly, the goal of HaH is to treat 
acutely ill older adults in their homes, while improving 
outcomes, enhancing the patient experience, and reducing 
costs.\16\ Researchers have found that HaH programs in other 
countries are associated with reductions in mortality, 
readmission rates, and costs. These studies have also found 
increases in patient and caregiver satisfaction.\17\ Early 
pilot studies in the U.S. show similar increases in patient 
satisfaction and decreases in cost without changes in 
readmission rates.\18\ However, evaluations of U.S. HaH 
programs are limited and inconclusive--and quality, cost, and 
equity concerns remain.\19\ Patients also often refuse 
participating when eligible for HaH.\20\
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 \16\Hospital-at-home, American Hospital Association (last visited 
on Mar. 8, 2024), https://www.aha.org/hospitalathome.
 \17\Gideon A Caplan et al., A meta-analysis of ``hospital in the 
home,'' 197:9 The Medical Journal of Australia 512-519 (2012), https://
onlinelibrary.wiley.com/doi/abs/10.5694/mja12.10480.
 \18\Sarah Klein, ``Hospital at Home'' Programs Improve Outcomes, 
Lower Costs But Face Resistance from Providers and Payers, The 
Commonwealth Fund (last visited on Mar. 8, 2024), https://
www.commonwealthfund.org/publications/newsletter-article/hospital-home-
programs-
improve-outcomes-lower-costs-face-resistance.
 \19\Medicare's Acute Care Hospital at Home Program, MedPAC (Sep. 8, 
2023), https://www.medpac.gov/wp-content/uploads/2023/03/Tab-F-ACHaH-
Sept-2023.pdf.
 \20\David M Levine et al., Hospital-Level Care at Home for Acutely 
Ill Adults: A Randomized Controlled Trial, 172:2 Annals Of Internal 
Medicine 77-85 (2020), https://www.acpjournals.org/doi/10.7326/M19-
0600.
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 AHCaH Evaluation. In September 2024, CMS released a 
Congressionally-mandated report on AHCaH. CMS found that 
patients participating in AHCaH were more likely to be White 
and from urban areas, and less likely to be eligible for forms 
of governmental assistance.\21\ The report found that the most-
used diagnostic codes were related to respiratory, circulatory, 
renal, and infectious disease conditions. While the report 
included some information, analysis and findings were 
insufficient to provide conclusive evidence related to the 
quality of care beneficiaries received in the home. 
Furthermore, the report skirted around the cost of AHCaH in the 
home, making any substantive comparisons or analyses on the 
cost inputs of care futile. Additional data and more robust 
analysis are necessary to determine how Medicare beneficiaries 
are using and hospitals are furnishing hospital-level care in 
the home.
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 \21\https://qualitynet.cms.gov/files/
66fae9162702fb414b540545?filename=AHCAH_Study_
092724.pdf.
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 Early AHCaH evaluations. In 2023, CMS released its first 
analysis of AHCaH data. CMS found that 8,417 Medicare FFS 
beneficiaries were admitted under an AHCaH waiver between 
November 25, 2021, and March 20, 2023.\22\ The most common 
diagnoses included respiratory infections, heart failure and 
shock, and severe sepsis or septicemia, all with major 
complication or comorbidity (MCC). The median length of stay 
was five days, 7.2 percent of patients were transferred back to 
the hospital, and 38 unexpected deaths occurred in 
participating hospitals, mostly due to COVID-19 infection. All 
but three deaths occurred after the patient was transferred 
back to the hospital and received medical and/or intensive care 
for several days before death. As of February 14, 2024, 315 
hospitals across 131 systems in 37 states are approved for 
AHCaH.\23\
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 \22\Danielle Adams et al., Initial Findings From an Acute Hospital 
Care at Home Waiver Initiative, JAMA Health Forum (Nov. 3, 2023), 
https://jamanetwork.com/journals/jama-health-forum/fullarticle/2811346.
 \23\Approved Facilities/Systems for Acute Hospital Care at Home, 
CMS QualityNet (last visited on Mar. 8, 2024), https://
qualitynet.cms.gov/acute-hospital-care-at-home/resources#tab1.
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 During its September 2023 public meeting, MedPAC flagged 
concerns about ACHaH, noting that 65 percent of hospitals 
approved for ACHaH had zero discharges (meaning they were not 
using the benefit) and active hospitals (those with at least 
one discharge) were more likely to be urban, non-profit, larger 
in size, and higher in occupancy.\24\ Of the 6,200 total ACHaH 
discharges in 2022, the largest 18 hospitals accounted for 62.5 
percent of the volume. MedPAC also stated that evaluating ACHaH 
will be challenging because beneficiaries self-select into the 
service, data on services provided during an ACHaH stay are 
limited, services provided and clinical conditions covered by 
participating hospitals varies by hospital, and the potential 
for higher at-home costs is great. While Commissioners broadly 
agreed safe and effective HaH programs could provide value in 
the right settings, they also expressed concerns about costs 
and the need for caregiver support, among other 
limitations.\25\ MedPAC will provide a full chapter on ACHaH in 
its upcoming report to Congress.
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 \24\Medicare's Acute Care Hospital at Home Program, MedPAC (Sep. 8, 
2023), https://www.medpac.gov/wp-content/uploads/2023/03/Tab-F-ACHaH 
Sept-2023.pdf.
 \25\Emma Hammer, MedPAC Holds September 2023 Meeting 09.15.2023, 
Applied Policy (Sep. 15, 2023), https://www.appliedpolicy.com/medpac-
holds-september-2023-meeting/.
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 Equity considerations. CMS' evaluation and MedPAC's 
analysis raise concerns about equitable access to HaH. First, 
patients participating in ACHaH are disproportionately White, 
and HaH uptake is primarily concentrated among larger urban 
hospitals. Hospitals must rethink current practices and develop 
the workforce and technical infrastructure necessary to support 
HaH, which may elude smaller or rural hospitals with fewer 
resources available for the necessary up-front 
investments.\26\\27\ Smaller hospitals, those in rural and 
underserved areas, and safety net hospitals may face challenges 
building the scale and capacity necessary to implement and 
sustain HaH, given that some estimate only five percent of 
Medicare discharges would be eligible for HaH.\28\ This 
translates to 15 patients per week for a 1,000-bed hospital. 
The digital infrastructure hospitals use to remotely monitor 
patients also demands a reliable and fast internet connection, 
sometimes unavailable in rural and underserved communities.\29\ 
The program as currently constituted favors larger urban 
hospital systems with greater resource capacity--as evidenced 
by early adopters, such as Johns Hopkins University Hospital, 
Mount Sinai Medical Center in New York City, and Mass General 
Brigham in Boston.
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 \26\Ksenia Gorbenko et al., A national qualitative study of 
Hospital-at-Home implementation under the CMS Acute Hospital Care at 
Home waiver, 71:1 Journal of the American Geriatrics Society 245-258 
(2022), https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/
jgs.18071.
 \27\Hospital at Home, Johns Hopkins Medicine (last visited on Mar. 
8, 2024), https://www.johnshopkinssolutions.com/solution/hospital-at-
home/.
 \28\Rosemary Batt & Eileen Appelbaum, The New Hospital-at-Home 
Movement: Opportunity or Threat for Patient Care?, 33:2 Public Policy & 
Aging Report? 63-69 (2023), https://
academic.oup.com/ppar/article/33/2/63/7147165.
 \29\Fady Sahhar & Mandy Sahhar, Home Health Series--The Challenges 
to Widespread Implementation of Hospital at Home Programs, The VBP Blog 
(Sep. 21, 2023), https://www.thevbpblog.com/home-health-series-the-
challenges-to-widespread-implementation-of-
hospital-at-home-programs/.
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 Second, patient selection into HaH could exacerbate 
existing disparities and disproportionately favor patients with 
more resources. Hospitals implementing HaH determine which 
services and patients are eligible for HaH, while also 
considering their own liability.\30\ In doing so, they may 
consider factors such as caregiver availability, housing 
conditions, and other perceived or required social supports 
needed for patients to successfully recover in the home 
environment. HaH may therefore serve certain populations more 
than others and access may be limited for historically 
marginalized communities that could benefit from it the most.
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 \30\David A Simon et al., The hospital-at-home presents novel 
liabilities for physicians, hospitals, caregivers, and patients, 28 
Nature Medicine 438-441 (2022), https://www.nature.com/articles/s41591-
022-01697-3.
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 Quality of care and patient safety concerns. Given the 
small sample size and data availability, it remains unclear 
whether HaH programs provide the same level and quality of 
acute care that acute care hospitals provide. Compromised 
quality and safety can happen for several reasons. First, under 
ACHaH, hospitals must be able to reach patients within 30 
minutes in the event of an emergency. That means if a patient 
needs to be transferred to a hospital, it could take up to an 
hour to begin receiving inpatient care.\31\ Studies show that 
patients are more likely to experience adverse events or die 
when critical care is delayed in an emergency.\32\
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 \31\Medicare's Hospital at Home Program is Dangerous for Patients, 
National Nurses United (Sep. 2022), https://
www.nationalnursesunited.org/sites/default/files/nnu/documents/
0922_Medicare_HospitalAtHome_Report.pdf.
 \32\Jack Chen et al., Delayed Emergency Team Calls and Associated 
Hospital Mortality: A Multicenter Study, 43:10 Critical Care Medicine 
2059-2065 (2015), https://journals.lww.com/ccmjournal/abstract/2015/
10000/delayed_emergency_team_calls_and_associated.3.aspx.
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 Second, hospitals must train existing staff, hire 
additional staff, or contract out to groups such as home health 
agencies (HHA) to fulfill the waiver obligation of two visits 
per day by a nurse or emergency medical technician (EMT). 
However, the 2024 CMS report on ACHaH did not provide 
sufficient data to analyze how hospitals were using or training 
staff for patients in ACHaH. In addition, in 2022, OIG released 
a report showing HHAs failed to report over half of falls with 
major injury and hospitalizations in their Medicare 
population.\33\ Some hospitals are also opting for less 
expensive EMTs for daily in-home visits rather than hiring 
nurses to make home visits. While this is allowable under the 
waiver and may be appropriate in certain circumstances, EMTs 
and nurses have different training, and the care they provide 
is not the same.\34\ Replacing nurses with paramedics or EMTs 
could degrade the quality of care patients receive in the home. 
In both cases, HHAs and EMT groups are increasingly owned by 
private equity groups that have come under scrutiny in recent 
years for maximizing profits at the expense of patient 
care.\35\\36\
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 \33\Home Health Agencies Failed To Report Over Half of Falls With 
Major Injury and Hospitalization Among Their Medicare Patients, U.S. 
Department of Health and Human Services, Office of Inspector General 
(Sep. 5, 2023), https://oig.hhs.gov/oei/reports/OEI-05-22-00290.asp.
 \34\Rosemary Batt & Eileen Appelbaum, The New Hospital-at-Home 
Movement: Opportunity or Threat for Patient Care?, 33:2 Public Policy & 
Aging Report? 63-69 (2023), https://
academic.oup.com/ppar/article/33/2/63/7147165.
 \35\Id.
 \36\Dangers Facing EMS: For-Profit Takeover, Emergicon (Nov. 14, 
2022), https://emergicon.com/blog/dangers-facing-ems-for-profit-
takeover/.
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 Third, substantial research over decades shows that higher 
nurse staffing levels and interdisciplinary care provided by 
care teams in hospitals improve care quality and reduce adverse 
events.\37\ Sending home patients who previously would have 
been admitted to the hospital--without the same supports or 
requirements for additional staffing--could lead to a drop in 
care quality. Understanding the implications of inpatient care 
provided in a home setting is critical, and more data is needed 
to determine if patient safety is compromised.
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 \37\Rosemary Batt & Eileen Appelbaum, The New Hospital-at-Home 
Movement: Opportunity or Threat for Patient Care?, Center for Economic 
and Policy Research (Jan. 24, 2023), https://cepr.net/report/the-new-
hospital-at-home-movement-opportunity-or-threat-for-patient-care/.
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 Questions about cost and payment. The 2024 CMS report on 
ACHaH did not provide data to determine the cost of providing 
hospital care in the home. The American Hospital Association 
(AHA) and its members point to reports of early HaH pilots that 
show potential savings of 20 to 40 percent compared to 
inpatient treatment.\38\ However, the small scale and limited 
sample size of pilots mostly in larger urban hospitals raises 
questions about whether these savings would be similar in other 
settings. It is also not clear whether cost savings seen in 
early pilots are representative of the true financial picture 
as programs expand--and who would benefit from those savings.
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 \38\Id.
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 At the same time, under ACHaH, Medicare pays hospitals at 
the inpatient rate despite far lower costs for in-home 
care.\39\ Some have raised questions about whether this is the 
appropriate payment level, including MedPAC commissioners, who 
expressed skepticism that payment should be on par with 
inpatient payment, given the care provided is different.\40\ 
The National Nurses Union has warned that there is a paucity of 
data to compare costs of HaH to inpatient care, and HaH shifts 
labor costs from hospitals to caregivers. Determining 
appropriate compensation under HaH is complex and involves 
considering both the upfront investment hospitals must make to 
provide care in the home as well as the cost savings hospitals 
see in the facility from shifting care.
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 \39\Id.
 \40\September 2023 Public Meeting Transcript, MedPAC (Sep. 7, 
2023), https://www.medpac.gov/wp-content/uploads/2023/03/September-
2023-meeting-transcript-v2-SEC.pdf.
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 Caregiver burden is often overlooked. Proponents of HaH 
make the case that the model allows patients to sleep better 
and spend more time with family members. At the same time, HaH 
places more burden on family members to serve as caregivers and 
de facto nurse aides by providing basic patient care, such as 
delivering meals and helping with hygiene.\41\\42\ It is 
important to be clear with caregivers the responsibility that 
comes with HaH arrangements and understand the added burden 
placed on caregivers as HaH expands. In addition, patients 
living alone or without family members with the ability to care 
for them may be altogether unable to access HaH.
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 \41\Kat McGowan, `Hospital-at-home' trend means family members must 
be caregivers--ready or not, NPR (July 18, 2023), https://www.npr.org/
sections/health-shots/2023/07/18/1188058399/hospital-at-home-
caregivers-family-stress.
 \42\Fady Sahhar & Mandy Sahhar, Home Health Series--The Challenges 
to Widespread Implementation of Hospital at Home Programs, The VBP blog 
(Sep. 21, 2023), https://www.thevbpblog.com/home-health-series-the-
challenges-to-widespread-implementation-of-
hospital-at-home-programs/.
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 Sincerely,
 Richard E. Neal,
 Ranking Member.