The pandemic conditions that propelled hospital-at-home programs in the United States may now be waning, but the movement itself is maintaining its momentum. According to the consulting firm McKinsey, up to $265 billion worth of care annually being delivered in health facilities for Medicare beneficiaries — a quarter of its total cost — could be relocated to homes by 2025. A recent report from Chartis, another consulting group, finds that nearly 40 percent of surveyed health executives intend to have implemented a hospital-at-home program in the next five years; only 10 percent or so of the respondents do not expect to develop any plan at all. When President Biden signed the $1.7 trillion omnibus spending bill at the end of December, the C.M.S. waiver became extended through 2024. Currently, no official rules limit what cases can be treated at home, so long as the care meets the same standard as inpatient care in the hospital wards, but the spending bill tasks the federal government with figuring out who should be hospitalized at home. In Leff’s vision, that could mean almost everyone eventually, improbable as that seems now. He imagines that one day hospitals will consist only of E.R.s, I.C.U.s and specialized operating rooms.
“When hospitals build a new building, they don’t do it themselves,” Pippa Shulman, the chief medical officer of Medically Home, told me. “We are the partner when you build a home-hospital.” Medically Home, a private company that started in 2016, has contracts with about 20 organizations, many of them signed during the pandemic. The firm choreographs the movements of local staff and suppliers, so that tests and visits can be carried out in people’s homes; if patients become too ill, they can be easily transported back to the hospital. Medically Home has created a technology platform to coordinate every step, so that — if everything is working right — a doctor will be able to make a computer entry and thereby prompt an action in the patient’s home as if it were being performed inside the hospital.
An increasing number of companies like Medically Home have moved into the home-hospital business, among them Contessa, DispatchHealth and Sena Health. Some firms provide only technology, like video calls or remote monitoring. Others not only set up a hospital’s operations but also manage insurance contracts; Mount Sinai needed reimbursements after its federal grant ran out, so it partnered with Contessa to deal with insurers. (DeCherrie, one of the doctors who led Mount Sinai’s original trial, has since gone to work at Medically Home; Leff advises some of these companies.) Consulting firms are selling their expertise to health executives. Even private insurers are becoming more involved, not only to reimburse hospitals for the care at home but also to provide the services themselves, sometimes by working with start-ups to remove the hospital from the equation. Their clinicians meet patients in their homes before they ever step foot in the E.R., as De Pirro did for Manuelita Romero.
In April 2020, Medically Home’s first hospital client, Kaiser Permanente Northwest — which, like Presbyterian, runs its own insurance plan — opened its hospital-at-home program. Because Oregon allows community paramedics to give in-home care, Kaiser Permanente is able to treat patients in that state using Medically Home’s nurses who are working out of a virtual command center in Massachusetts. During a typical day, these patients can expect video calls with their doctor and nurse and in-person visits from a medic, who checks their vital signs and gives medication. Ultrasounds, X-rays, even echocardiograms can be done in the home. For certain problems, like wound care, nurse practitioners might trek out to a house. The nursing and doctoring remain mostly virtual, however, unlike the treatment given through Presbyterian; a Kaiser Permanente patient might be hospitalized in his home in Longview, Wash., while his doctor is in Portland and his nurse is in Boston.
In this way, Kaiser Permanente has served more than 2,000 patients in Washington and Oregon; nearly 500 more have been treated in its California program, which began in late 2020. To put these numbers in perspective, Presbyterian’s hospital-at-home has cared for fewer than 1,600 patients since its debut 15 years ago. Kaiser Permanente needs to operate on a scale like this, according to its executives, to offset the substantial investment that went into starting its hospital-at-home program. “There is cost to getting these programs off the ground,” says Mary Giswold, the chief operating officer of Kaiser Permanente Northwest. To cover them, Giswold explains, hospitals need to reach certain economies of scale. This may be another reason C.M.S. didn’t support hospital-at-home after the Mount Sinai study: To make financial sense, a hospital probably needs to treat at least 200 patients at home annually — a struggle for many places to reach at the time.
Making hospital-at-home cost-effective for health systems comes with a different kind of cost, though. A patient may never feel the warmth of her nurse’s hand on her forehead, the reassurance of her doctor’s stethoscope over her heart. During a video visit that I sat in on, involving Kaiser Permanente’s program, the only glimpse I caught of the patient’s home was a bottle of Tums and a mug on her side table — a far cry from what De Pirro is able to see on her rounds. When the patient noted some lower abdominal pain, the doctor couldn’t reach through the screen to examine her; instead, he had to rely on a medic’s report. Arsheeya Mashaw, the medical director of Kaiser Permanente at Home for the Northwest, recognizes the trade-offs. “Although I’m sacrificing that bedside interaction with the patient,” Mashaw told me, “I’m also increasing the amount of patients I can see a day to provide that better care in home to the patient, which kind of makes up for the losses.”
