[House Report 119-359]
[From the U.S. Government Publishing Office]
119th Congress } { Report
HOUSE OF REPRESENTATIVES
1st Session } { 119-359
======================================================================
HOSPITAL INPATIENT SERVICES MODERNIZATION ACT
_______
October 31, 2025.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Smith of Missouri, from the Committee on Ways and Means, submitted
the following
R E P O R T
together with
SUPPLEMENTAL VIEWS
[To accompany H.R. 4313]
The Committee on Ways and Means, to whom was referred the
bill (H.R. 4313) to amend title XVIII of the Social Security
Act to extend acute hospital care at home waiver flexibilities,
and to require an additional study and report on such
flexibilities, having considered the same, reports favorably
thereon with an amendment and recommends that the bill as
amended do pass.
CONTENTS
Page
I. SUMMARY AND BACKGROUND........................................ 3
A. Purpose and Summary................................. 3
B. Background and Need for Legislation................. 3
C. Legislative History................................. 3
D. Designated Hearing.................................. 4
II. EXPLANATION OF THE BILL...................................... 4
A. Reasons for Change.................................. 4
B. Explanation of Provisions........................... 4
C. Effective Date...................................... 4
III. VOTES OF THE COMMITTEE...................................... 4
IV. BUDGET EFFECTS OF THE BILL................................... 7
A. Committee Estimate of Budgetary Effects............. 7
B. Statement Regarding New Budget Authority and Tax
Expenditures Budget Authority...................... 7
C. Cost Estimate Prepared by the Congressional Budget
Office............................................. 8
V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE.... 8
A. Committee Oversight Findings and Recommendations.... 8
B. Statement of General Performance Goals and
Objectives......................................... 8
C. Information Relating to Unfunded Mandates........... 8
D. Congressional Earmarks, Limited Tax Benefits, and
Limited Tariff Benefits............................ 8
E. Duplication of Federal Programs..................... 8
VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED........ 9
VII. SUPPLEMENTAL VIEWS......................................... 14
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Hospital Inpatient Services
Modernization Act''.
SEC. 2. EXTENDING ACUTE HOSPITAL CARE AT HOME WAIVER FLEXIBILITIES.
Section 1866G(a)(1) of the Social Security Act (42 U.S.C. 1395cc-
7(a)(1)) is amended by striking ``2025'' and inserting ``2030''.
SEC. 3. REQUIRING ADDITIONAL STUDY AND REPORT ON ACUTE HOSPITAL CARE AT
HOME WAIVER FLEXIBILITIES.
Section 1866G of the Social Security Act (42 U.S.C. 1395cc-7), as
amended by section 2, is further amended--
(1) in subsection (a)(3)(E)--
(A) in clause (ii), by striking ``the study described
in subsection (b)'' and inserting ``the studies
described in subsections (b) and (c)''; and
(B) by adding at the end the following new flush
sentence:
``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.'';
(2) in subsection (b), in the subsection heading, by striking
``Study'' and inserting ``Initial Study'';
(3) by redesignating subsections (c) and (d) as subsections
(d) and (e), respectively; and
(4) by inserting after subsection (b) the following new
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).''.
I. SUMMARY AND BACKGROUND
A. Purpose and Summary
The policy would extend the Acute Hospital at Home
Initiative through December 31, 2030, and require the Centers
for Medicare & Medicaid Services (CMS) to conduct a study of
the waiver and submit a report to the House Committee on Ways &
Means and the Senate Committee on Finance no later than
September 30, 2028.
B. Background and Need for Legislation
Generally, to participate in the Medicare program,
hospitals must comply with Medicare's basic health and safety
rules, called Conditions of Participation (CoPs), as well as a
variety of other regulatory requirements. In 2020, as part of
the CMS response to the Covid-19 public health emergency (PHE),
the Trump Administration launched the Hospital Without Walls
Initiative and its constituent part, the Acute Hospital at Home
Initiative (Initiative), designed to provide hospitals needed
flexibility to increase hospital capacity. To do this, the
Initiative leveraged Section 1135 of the Social Security Act to
waive Medicare CoPs and other statutory and regulatory
requirements, enabling hospitals to provide inpatient care in
beneficiaries' homes. The Initiative was due to end upon the
expiration of the Covid-19 PHE, but Congress extended it
through December 31, 2024, requiring the Secretary of Health
and Human Services to submit to Congress a report on the
Initiative's status by the conclusion of Fiscal Year 2024. CMS
submitted the report in September 2024. Congress extended the
waiver through September 30, 2025, and legislative action is
needed to extend the Acute Hospital at Home waiver past that
date.
C. Legislative History
Background
H.R. 4313 was introduced on July 10, 2025, and was referred
to the Committee on Ways and Means.
Committee Hearings
The Committee on Ways and Means held the following
hearing(s) concerning the policy in H.R. 4313:
On June 25, 2025, the Ways and Means Subcommittee on Health
held a hearing titled ``Health at Your Fingertips: Harnessing
the Power of Digital Health Data'' where access to technologies
including those used through the Acute Hospital at Home
Initiative were discussed.
Committee Action
The Committee on Ways and Means marked up H.R. 4313, the
``Hospital Inpatient Services Modernization Act'' on September
17, 2025, and favorably reported the bill, as amended, to the
House of Representatives (with quorum being present).
D. Designated Hearing
Pursuant to clause 3(c)(6) of rule XIII, the following
hearing was used to develop and consider H.R. 8261:
On June 25, 2025, the Ways and Means Subcommittee on Health
held a hearing titled ``Health at Your Fingertips: Harnessing
the Power of Digital Health Data''.
II. EXPLANATION OF THE BILL
A. Reasons for Change
The Initiative will expire after September 30, 2025, absent
congressional action.
B. Explanation of Provisions
The policy would extend the Initiative through December 31,
2030, and require CMS to conduct a study of the waiver and
submit a report to the House Committee on Ways & Means and the
Senate Committee on Finance no later than September 30, 2028.
C. Effective Date
The bill, as amended, would become effective upon
enactment.
III. VOTES OF THE COMMITTEE
In compliance with the Rules of the House of
Representatives, the following statement is made concerning the
vote of the Committee on Ways and Means during the markup
consideration of H.R. 4313, the ``Hospital Inpatient Services
Modernization Act,'' on September 17, 2025.
The vote on Mr. Buchanan's motion to table Mr. Horsford's
appeal of the ruling of the chair was agreed to by a roll call
vote of 26 yeas to 15 nays (with a quorum being present). The
vote was as follows:
----------------------------------------------------------------------------------------------------------------
Representative Yea Nay Present Representative Yea Nay Present
----------------------------------------------------------------------------------------------------------------
Mr. Smith (MO)..................... X ...... ......... Mr. Neal............. ...... X .........
Mr. Buchanan....................... X ...... ......... Mr. Doggett.......... ...... X .........
Mr. Smith (NE)..................... X ...... ......... Mr. Thompson......... ...... X .........
Mr. Kelly.......................... X ...... ......... Mr. Larson........... ...... X .........
Mr. Schweikert..................... X ...... ......... Mr. Davis............ ...... ...... .........
Mr. LaHood......................... X ...... ......... Ms. Sanchez.......... ...... ...... .........
Mr. Arrington...................... X ...... ......... Ms. Sewell........... ...... ...... .........
Mr. Estes.......................... X ...... ......... Ms. DelBene.......... ...... X .........
Mr. Smucker........................ X ...... ......... Ms. Chu.............. ...... X .........
Mr. Hern........................... X ...... ......... Ms. Moore............ ...... X .........
Mrs. Miller........................ X ...... ......... Mr. Boyle............ ...... X .........
Dr. Murphy......................... X ...... ......... Mr. Beyer............ ...... X .........
Mr. Kustoff........................ X ...... ......... Mr. Evans............ ...... X .........
Mr. Fitzpatrick.................... X ...... ......... Mr. Schneider........ ...... X .........
Mr. Steube......................... X ...... ......... Mr. Panetta.......... ...... X .........
Ms. Tenney......................... X ...... ......... Mr. Gomez............ ...... X .........
Mrs. Fischbach..................... X ...... ......... Mr. Horsford......... ...... X .........
Mr. Moore.......................... X ...... ......... Ms. Plaskett......... ...... ...... .........
Ms. Van Duyne...................... X ...... ......... Mr. Suozzi........... ...... X .........
Mr. Feenstra....................... X ...... .........
Ms. Malliotakis.................... X ...... .........
Mr. Carey.......................... X ...... .........
Mr. Yakym.......................... X ...... .........
Mr. Miller......................... X ...... .........
Mr. Bean........................... X ...... .........
Mr. Moran.......................... X ...... .........
----------------------------------------------------------------------------------------------------------------
In compliance with the Rules of the House of
Representatives, the following statement is made concerning the
vote of the Committee on Ways and Means during the markup
consideration of H.R. 4313, the ``Hospital Inpatient Services
Modernization Act,'' on September 17, 2025.
The vote on Mr. Buchanan's motion to table Mr. Thompson's
appeal of the ruling of the chair was agreed to by a roll call
vote of 26 yeas to 17 nays (with a quorum being present). The
vote was as follows:
----------------------------------------------------------------------------------------------------------------
Representative Yea Nay Present Representative Yea Nay Present
----------------------------------------------------------------------------------------------------------------
Mr. Smith (MO)..................... X ...... ......... Mr. Neal............. ...... X .........
Mr. Buchanan....................... X ...... ......... Mr. Doggett.......... ...... X .........
Mr. Smith (NE)..................... X ...... ......... Mr. Thompson......... ...... X .........
Mr. Kelly.......................... X ...... ......... Mr. Larson........... ...... X .........
Mr. Schweikert..................... X ...... ......... Mr. Davis............ ...... X .........
Mr. LaHood......................... X ...... ......... Ms. Sanchez.......... ...... ...... .........
Mr. Arrington...................... X ...... ......... Ms. Sewell........... ...... ...... .........
Mr. Estes.......................... X ...... ......... Ms. DelBene.......... ...... X .........
Mr. Smucker........................ X ...... ......... Ms. Chu.............. ...... X .........
Mr. Hern........................... X ...... ......... Ms. Moore............ ...... X .........
Mrs. Miller........................ X ...... ......... Mr. Boyle............ ...... X .........
Dr. Murphy......................... X ...... ......... Mr. Beyer............ ...... X .........
Mr. Kustoff........................ X ...... ......... Mr. Evans............ ...... X .........
Mr. Fitzpatrick.................... X ...... ......... Mr. Schneider........ ...... X .........
Mr. Steube......................... X ...... ......... Mr. Panetta.......... ...... X .........
Ms. Tenney......................... X ...... ......... Mr. Gomez............ ...... X .........
Mrs. Fischbach..................... X ...... ......... Mr. Horsford......... ...... X .........
Mr. Moore.......................... X ...... ......... Ms. Plaskett......... ...... X .........
Ms. Van Duyne...................... X ...... ......... Mr. Suozzi........... ...... X .........
Mr. Feenstra....................... X ...... .........
Ms. Malliotakis.................... X ...... .........
Mr. Carey.......................... X ...... .........
Mr. Yakym.......................... X ...... .........
Mr. Miller......................... X ...... .........
Mr. Bean........................... X ...... .........
Mr. Moran.......................... X ...... .........
----------------------------------------------------------------------------------------------------------------
In compliance with the Rules of the House of
Representatives, the following statement is made concerning the
vote of the Committee on Ways and Means during the markup
consideration of H.R. 4313, the ``Hospital Inpatient Services
Modernization Act,'' on September 17, 2025.
The vote on Mr. Buchanan's motion to table Ms. Chu's appeal
of the ruling of the chair was agreed to by a roll call vote of
26 yeas to 16 nays (with a quorum being present). The vote was
as follows:
----------------------------------------------------------------------------------------------------------------
Representative Yea Nay Present Representative Yea Nay Present
----------------------------------------------------------------------------------------------------------------
Mr. Smith (MO)..................... X ...... ......... Mr. Neal............. ...... X .........
Mr. Buchanan....................... X ...... ......... Mr. Doggett.......... ...... X .........
Mr. Smith (NE)..................... X ...... ......... Mr. Thompson......... ...... X .........
Mr. Kelly.......................... X ...... ......... Mr. Larson........... ...... X .........
Mr. Schweikert..................... X ...... ......... Mr. Davis............ ...... X .........
Mr. LaHood......................... X ...... ......... Ms. Sanchez.......... ...... ...... .........
Mr. Arrington...................... X ...... ......... Ms. Sewell........... ...... ...... .........
Mr. Estes.......................... X ...... ......... Ms. DelBene.......... ...... X .........
Mr. Smucker........................ X ...... ......... Ms. Chu.............. ...... X .........
Mr. Hern........................... X ...... ......... Ms. Moore............ ...... X .........
Mrs. Miller........................ X ...... ......... Mr. Boyle............ ...... X .........
Dr. Murphy......................... X ...... ......... Mr. Beyer............ ...... X .........
Mr. Kustoff........................ X ...... ......... Mr. Evans............ ...... X .........
Mr. Fitzpatrick.................... X ...... ......... Mr. Schneider........ ...... X .........
Mr. Steube......................... X ...... ......... Mr. Panetta.......... ...... ...... .........
Ms. Tenney......................... X ...... ......... Mr. Gomez............ ...... X .........
Mrs. Fischbach..................... X ...... ......... Mr. Horsford......... ...... X .........
Mr. Moore.......................... X ...... ......... Ms. Plaskett......... ...... X .........
Ms. Van Duyne...................... X ...... ......... Mr. Suozzi........... ...... X .........
Mr. Feenstra....................... X ...... .........
Ms. Malliotakis.................... X ...... .........
Mr. Carey.......................... X ...... .........
Mr. Yakym.......................... X ...... .........
Mr. Miller......................... X ...... .........
Mr. Bean........................... X ...... .........
Mr. Moran.......................... X ...... .........
----------------------------------------------------------------------------------------------------------------
In compliance with the Rules of the House of
Representatives, the following statement is made concerning the
vote of the Committee on Ways and Means during the markup
consideration of H.R. 4313, the ``Hospital Inpatient Services
Modernization Act,'' on September 17, 2025.
The vote on Mr. Buchanan's motion to table Mr. Schneider's
appeal of the ruling of the chair was agreed to by a roll call
vote of 25 yeas to 18 nays (with a quorum being present). The
vote was as follows:
----------------------------------------------------------------------------------------------------------------
Representative Yea Nay Present Representative Yea Nay Present
----------------------------------------------------------------------------------------------------------------
Mr. Smith (MO)..................... X ...... ......... Mr. Neal............. ...... X .........
Mr. Buchanan....................... X ...... ......... Mr. Doggett.......... ...... X .........
Mr. Smith (NE)..................... X ...... ......... Mr. Thompson......... ...... X .........
Mr. Kelly.......................... X ...... ......... Mr. Larson........... ...... X .........
Mr. Schweikert..................... X ...... ......... Mr. Davis............ ...... X .........
Mr. LaHood......................... X ...... ......... Ms. Sanchez.......... ...... ...... .........
Mr. Arrington...................... ...... ...... ......... Ms. Sewell........... ...... X .........
Mr. Estes.......................... X ...... ......... Ms. DelBene.......... ...... X .........
Mr. Smucker........................ X ...... ......... Ms. Chu.............. ...... X .........
Mr. Hern........................... X ...... ......... Ms. Moore............ ...... X .........
Mrs. Miller........................ X ...... ......... Mr. Boyle............ ...... X .........
Dr. Murphy......................... X ...... ......... Mr. Beyer............ ...... X .........
Mr. Kustoff........................ X ...... ......... Mr. Evans............ ...... X .........
Mr. Fitzpatrick.................... X ...... ......... Mr. Schneider........ ...... X .........
Mr. Steube......................... X ...... ......... Mr. Panetta.......... ...... X .........
Ms. Tenney......................... X ...... ......... Mr. Gomez............ ...... X .........
Mrs. Fischbach..................... X ...... ......... Mr. Horsford......... ...... X .........
Mr. Moore.......................... X ...... ......... Ms. Plaskett......... ...... X .........
Ms. Van Duyne...................... X ...... ......... Mr. Suozzi........... ...... X .........
Mr. Feenstra....................... X ...... .........
Ms. Malliotakis.................... X ...... .........
Mr. Carey.......................... X ...... .........
Mr. Yakym.......................... X ...... .........
Mr. Miller......................... X ...... .........
Mr. Bean........................... X ...... .........
Mr. Moran.......................... X ...... .........
----------------------------------------------------------------------------------------------------------------
In compliance with the Rules of the House of
Representatives, the following statement is made concerning the
vote of the Committee on Ways and Means during the markup
consideration of H.R. 4313, the ``Hospital Inpatient Services
Modernization Act,'' on September 17, 2025.
H.R. 4313 was ordered favorably reported to the House of
Representatives as amended by a roll call vote of 44 yeas to 0
nays (with a quorum being present). The vote was as follows:
----------------------------------------------------------------------------------------------------------------
Representative Yea Nay Present Representative Yea Nay Present
----------------------------------------------------------------------------------------------------------------
Mr. Smith (MO)..................... X ...... ......... Mr. Neal............. X ...... .........
Mr. Buchanan....................... X ...... ......... Mr. Doggett.......... X ...... .........
Mr. Smith (NE)..................... X ...... ......... Mr. Thompson......... X ...... .........
Mr. Kelly.......................... X ...... ......... Mr. Larson........... X ...... .........
Mr. Schweikert..................... X ...... ......... Mr. Davis............ X ...... .........
Mr. LaHood......................... X ...... ......... Ms. Sanchez.......... ...... ...... .........
Mr. Arrington...................... X ...... ......... Ms. Sewell........... X ...... .........
Mr. Estes.......................... X ...... ......... Ms. DelBene.......... X ...... .........
Mr. Smucker........................ X ...... ......... Ms. Chu.............. X ...... .........
Mr. Hern........................... X ...... ......... Ms. Moore............ X ...... .........
Mrs. Miller........................ X ...... ......... Mr. Boyle............ X ...... .........
Dr. Murphy......................... X ...... ......... Mr. Beyer............ X ...... .........
Mr. Kustoff........................ X ...... ......... Mr. Evans............ X ...... .........
Mr. Fitzpatrick.................... X ...... ......... Mr. Schneider........ X ...... .........
Mr. Steube......................... X ...... ......... Mr. Panetta.......... X ...... .........
Ms. Tenney......................... X ...... ......... Mr. Gomez............ X ...... .........
Mrs. Fischbach..................... X ...... ......... Mr. Horsford......... X ...... .........
Mr. Moore.......................... X ...... ......... Ms. Plaskett......... X ...... .........
Ms. Van Duyne...................... X ...... ......... Mr. Suozzi........... X ...... .........
Mr. Feenstra....................... X ...... ......... ..................... ...... ...... .........
Ms. Malliotakis.................... X ...... ......... ..................... ...... ...... .........
Mr. Carey.......................... X ...... ......... ..................... ...... ...... .........
Mr. Yakym.......................... X ...... ......... ..................... ...... ...... .........
Mr. Miller......................... X ...... ......... ..................... ...... ...... .........
Mr. Bean........................... X ...... ......... ..................... ...... ...... .........
Mr. Moran.......................... X ...... ......... ..................... ...... ...... .........
----------------------------------------------------------------------------------------------------------------
IV. BUDGET EFFECTS OF THE BILL
A. Committee Estimate of Budgetary Effects
With respect to clause 3(d) of rule XIII of the Rules of
the House of Representatives, a cost estimate provided by the
Congressional Budget Office pursuant to section 402 of the
Congressional Budget Act of 1974 was not made available to the
Committee in time for the filing of this report.
B. Statement Regarding New Budget Authority and Tax Expenditures Budget
Authority
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee states that the
bill involved no new or increased budget authority. The
Committee states further that the bill involves no new or
increased tax expenditures.
C. Cost Estimate Prepared by the Congressional Budget Office
With respect to the requirements of clause 3(c)(2) of rule
XIII of the Rules of the House of Representatives and section
308(a) of the Congressional Budget Act of 1974 and with respect
to requirements of clause (3)(c)(3) of rule XIII of the Rules
of the House of Representatives and section 402 of the
Congressional Budget Act of 1974, the Committee has requested
but not received a cost estimate for this bill from the
Director of Congressional Budget Office. The Chairman of the
Committee shall cause such estimate and statement to be printed
in the Congressional Record upon its receipt by the Committee.
V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE
A. Committee Oversight Findings and Recommendations
With respect to clause 3(c)(1) of rule XIII of the Rules of
the House of Representatives, the Committee made findings and
recommendations that are reflected in this report.
B. Statement of General Performance Goals and Objectives
With respect to clause 3(c)(4) of rule XIII of the Rules of
the House of Representatives, the Committee advises that the
bill does not authority funding, so no statement of general
performance goals and objectives is required.
C. Information Relating to Unfunded Mandates
This information is provided in accordance with section 423
of the Unfunded Mandates Reform Act of 1995 (Pub. L. No. 104-
4).
The Committee has determined that the bill does not contain
Federal mandates on the private sector. The Committee has
determined that the bill does not impose a Federal
intergovernmental mandate on State, local, or tribal
governments.
D. Congressional Earmarks, Limited Tax Benefits, and Limited Tariff
Benefits
With respect to clause 9 of rule XXI of the Rules of the
House of Representatives, the Committee has carefully reviewed
the provisions of the bill, and states that the provisions of
the bill do not contain any congressional earmarks, limited tax
benefits, or limited tariff benefits within the meaning of the
rule.
E. Duplication of Federal Programs
In compliance with clause 3(c)(5) of rule XIII of the Rules
of the House of Representatives, the Committee states that no
provision of the bill establishes or reauthorizes: (1) a
program of the Federal Government known to be duplicative of
another Federal program; (2) a program included in any report
from the Government Accountability Office to Congress pursuant
to section 21 of Public Law 111-139; or (3) a program related
to a program identified in the most recent Catalog of Federal
Domestic Assistance, published pursuant to the Federal Program
Information Act (Pub. L. No. 95-220, as amended by Pub. L. No.
98-169).
VI. 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
* * * * * * *
TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED
* * * * * * *
Part E--Miscellaneous Provisions
* * * * * * *
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).
* * * * * * *
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.
---------------------------------------------------------------------------
\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.
---------------------------------------------------------------------------
\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.
---------------------------------------------------------------------------
\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.
[all]