COVID-19 has transformed the US healthcare system, straining intensive care unit capacity,  upending traditional care delivery modalities, which require face-to-face interactions, and exposing the access gap for at-risk populations. As part of the response to these developments, demand for home-based care, which encompasses an increasingly diverse array of clinical services delivered in a patient’s home, has increased significantly and evolved quickly. New companies, disruptors, and innovative provider groups have emerged to meet this growing demand for in-home care across the healthcare continuum, as depicted in Figure 1.

The Moving Health Home coalition commissioned Avalere to conduct a series of interviews with clinical and business leaders to explore the transformation that home-based care has undergone during the pandemic and identify a set of federal and state policy implications. While recognition of the benefits of home-based care continues to grow, policymakers and other stakeholders may continue to explore mechanisms for reducing the barriers in accessing home-based care beyond the pandemic.

Identifying the Policy and Regulatory Barriers

Interviewees suggested that regulatory flexibilities put in place during the COVID-19 public health emergency (PHE) were the primary driver for spurring diffusion of in-home care programs. However, uncertainty about the post-COVID-19 policy environment and persistent challenges related to conditions of participation and state-level provider requirements limit further scale. Specific barriers are described in further detail below.

Barrier 1: Uncertain Regulatory Environment in a Post-PHE World

Home-based care benefited from a host of PHE-related waivers that created new care options for Medicare Fee-For-Service beneficiaries, ranging from the Hospital Without Walls/Acute Hospital Care at Home to the telehealth, durable medical equipment, and skilled nursing facility 3-day stay waivers. It is unclear whether these short-term regulatory changes will be made permanent through formal rulemaking by the Centers for Medicare & Medicaid Services (CMS) or congressional action. Findings from the interviews indicated that without visibility into the future regulatory structure, in-home care innovators have struggled to make long-term investments to expand services and develop new clinical and business models.

Barrier 2: Overly Restrictive Requirements for Hospital at Home Programs

The Acute Hospital Care at Home program provided eligible health systems with regulatory flexibilities to treat eligible patients in their homes. However, some interviewees said that the requirements are too onerous for non-traditional healthcare delivery systems to participate. The CMS may consider relaxing requirements to encourage participation from more community-based, non-hospital providers.

Barrier 3: Significant Variability in Provider Requirements Across States

In addition to federal policy barriers, interviewees described state-level policies, including those related to provider licensing and oversight, that limit the proliferation of home-based care. Additionally, many state regulators conflate home-based care (e.g., geriatric-focused primary care) with the services provided by home health agencies. State policymakers may need to consider opportunities to provide more appropriate oversight for home-based care service providers so that it aligns more closely to service offerings.

Looking Ahead

Action to formalize the regulatory flexibilities granted under the PHE may not materialize in 2022. However, as the omicron and other COVID-19 variants persist as a continued threat, time-limited regulatory flexibilities, such as waivers and other programs, may be extended by Congress. Additionally, other avenues, including testing and evaluating the impact of these waivers as a model under CMMI authority, could be employed to ensure home-based care organizations maintain a level of consistency and access to flexible payment mechanisms. The recent publication of the Innovation Center Strategy Refresh specifically points to flexibility around home-based care and treatment as a potential mechanism for supporting care innovation, 1 of their 5 strategic objectives, providing insight into potential opportunities to formalize and expand home-based care. However, as CMMI models are still temporary in nature, there may be additional calls for Congress to authorize permanent expansions of home-based waivers that build on lessons learned during the pandemic and include additional innovative design elements.

Download the white paper to read more.

To receive Avalere updates, connect with us.