On March 15, President Trump signed the continuing resolution passed by Congress, which extended COVID-19-era Centers for Medicare and Medicaid Services regulations applicable to telehealth and hospital-at-home through September 30, 2025.
It’s only the most recent of several months-long extensions. Healthcare organizations simultaneously breathed a sigh of relief and continued to be frustrated that their ability to plan for the future was limited once again.
For telehealth, the CR extended flexibilities that remove geographic boundaries and expand telehealth service originating locations (including patients’ homes), permit more providers and services to be eligible for telehealth reimbursement, allow for audio-only visits, remove requirements for an initial in-person visit for behavioral health, and extend telehealth services for Federally Qualified Health Centers and Rural Health Clinics.
The extension of the hospital-at-home waiver, formally known as the Acute Hospital Care at Home initiative, or AHCAH, enables full Diagnosis Related Group-based reimbursement for Medicare patients who are provided hospital-level care in their homes.
Bipartisan support
While the waiver extensions for both telehealth and hospital-at-home have bipartisan support, healthcare executives are deeply concerned the tangible benefits of each initiative will be lost, or not fully realized, if a long-term solution is not codified and executives are further stymied in their planning efforts.
The result of this ongoing uncertainty is a limited appetite for the meaningful investments required to scale telehealth initiatives and hospital-at-home and make them a permanent part of a health system’s care delivery ecosystem.
For hospital-at-home there still is optimism there will be a further extension of the CMS waiver for several reasons. The program is cost-neutral to CMS (or even favorable), there is bipartisan support, and providers and researchers have built a positive story that resonates with policymakers.
The same is generally true for telehealth: there’s advocacy across the political spectrum and highly favorable patient experiences. The sticking point is the significant costs associated with the expanded reimbursement provisions. In today’s political environment, these costs may result in the elimination of specific programmatic elements.
Who has the CMS waivers
“As of March 17, 2025, 400 hospitals within 143 health systems across 39 states have been granted AHCAH waivers by CMS,” reported Jon Freedman, partner, digital and technology transformation, at Chartis. “This includes more than 20 hospitals being granted waivers in 2025. So, for hospital-at-home, there has been and still is substantial interest from a broad swath of providers.
“For providers who have not yet launched a hospital-at-home program, this uncertainty means they’re unlikely to invest substantially at this stage,” he continued. “Many will use this time to do what they should be doing anyway: building a business case to deeply evaluate the economic, clinical, operational, technical and cultural implications of standing up a program.”
In terms of the economic implications – which of course has the biggest impact if the CMS waiver is not extended – many hospital systems will likely find there is substantial economic benefit to hospital-at-home, even without the reimbursement, he added.
“Providers with existing programs are at different levels of maturity, and their position on the maturity curve guides their current outlook,” Freedman explained. “Those with substantial programs realizing a return on their investments and experiencing improved care quality and patient experience are likely to continue to invest. While they risk taking a revenue hit on losing Medicare reimbursement, the value derived from maintaining and expanding their program far outweighs that risk.
“Health systems with less mature programs, generally those with an average daily census of under 15, tend to be in a wait-and-see mode,” he continued. “Similar to systems that don’t have existing programs, providers are also taking the opportunity to refresh, or build, their business cases. These are programs that launched hospital-at-home during COVID when urgency, not strategy, was the main driver.”
Right-size the approach
As a result, a lot of this initial investment and commitment was haphazard and “side-of-desk” work; however, many systems have seen the potential for hospital-at-home and are taking the opportunity to right-size the approach to have a meaningful impact.
“Payers and vendors for hospital-at-home services and technology are patiently waiting to act,” Freedman noted. “Commercial payers have generally been taking the lead with CMS reimbursement. While they recognize that the lower cost model of hospital-at-home has appealing potential and can fit well into their business models, including in risk-based arrangements, they are hesitant to invest substantially until the regulatory environment is more stable.
“Similarly, technology vendors will maintain their products and services and keep executing against already planned roadmaps but may not invest in de novo capabilities until market positioning is clarified,” he added.
For all players, hospital-at-home uncertainty is driving many to consider how to apply their hospital-at-home chassis to a broader care-at-home ecosystem. Many of the same clinical services, technology tools (like RPM), logistics and personnel that apply to hospital-at-home apply to other home-based care use cases.
Other use cases
“More advanced health systems already have started to expand this chassis, and others are starting with other care-at-home scenarios,” Freedman said. “In California, for example, where hospital-at-home is still not permitted on a state level, select leading health systems are moving forward with building out these other use cases.
“The problems faced by health systems are not changing regardless of the regulatory status of solutions,” he continued. “They are over-capacity and capital-constrained, and their access challenges are profound. The home is rapidly becoming a viable and accepted site of care for patients at various stages of acuity and for many conditions.”
While the economics of CMS-reimbursed hospital-at-home can be a robustly accretive strategic move for health systems, the benefits without the promise for equal reimbursement across the care-at-home space addresses numerous problems, he added.
For telehealth, providers, payers and technology vendors are looking at contingency plans if waiver extensions are even partially discontinued. In many cases, organizations are resurrecting plans they developed before the previous extensions, when uncertainty was prevalent.
Telehealth is getting more deeply embedded
“The greater challenge today is that with every passing extension, telehealth gets more deeply infused into care models,” Freedman explained. “Patients have come to rely on, and demand, more versatile ways of engaging with their providers – who have increasingly incorporated telehealth into their operations.
“Vendors have continued to build out capabilities and services,” he continued. “Payers have partnered with providers to incorporate telehealth into risk-based arrangements and have started working with vendors to provide telehealth services directly to consumers, to lower costs of care. It is no doubt a complex web.”
Providers and payers, who provide direct telehealth care to their members, have found telehealth presents a great opportunity to provide greater access to more patients for increased services and providers. Relaxed rules around in-person visits, originating sites and geographical requirements have enabled health systems to partner with other service companies and other health systems to build care supply to meet increased demand.
Without these expanded services, care supply will again be limited.
Significant impacts
“FQHCs and RHCs will be particularly limited – both of which have been able to provide significantly more equitable care and fill an unmet need through telehealth,” Freedman said. “In addition, behavioral health, arguably the service line that has benefited most from telehealth advancements, will also be significantly impacted.
“Progress made over the last few years will be significantly halted because of the requirements for initial in-person visits being reinstated, geographic implications, and massive shortages in behavioral health care supply,” he continued.
In addition to significant access issues, all parties have increasingly integrated telehealth economics into their operating models, he added.
“Scaling services to additional patients through more modalities has become increasingly pivotal for risk-based arrangements,” he noted. “And, even in the case of fee-for-service, not getting reimbursed for audio-only calls will affect a health system’s ability to engage with the patients who need it most. While this reimbursement didn’t pay for the services in their entirety, it helped.
“Moreover, the lack of reimbursement for audio-only calls significantly and negatively impacts patients without reliable digital connections or those who are not digitally astute, further exacerbating health inequity,” he added.
Economic and non-economic benefits
Hospital-at-home benefits can be put into two primary buckets: direct economic benefits and non-economic benefits.
“On the economic benefit side, the relative weight of the benefits varies from system to system,” Freedman explained. “The most important levers are the relief of capacity constraints and subsequent backfill with higher acuity patients, capital avoidance and stand-alone profitability. A recent study suggests hospital capacity issues are pervasive and will only persist and exacerbate over time.
“By serving less acute populations at home, hospitals can open up beds for patients with more complex medical needs,” he continued. “In terms of capital avoidance, even with the investment required for hospital-at-home, hospitals will still be able to create more capacity for less cost – and still provide highly effective, safe care – than the $2-$4 million per bed costs of a new hospital.”
Finally, assuming CMS reimbursement is at parity and commercial reimbursement remains at a reasonable level, the economics of a hospital-at-home program can be highly favorable, he added.
For non-economic benefits, first and foremost is the actual care that patients receive. Numerous studies have shown hospital-at-home to be safe and effective, and there is uniformly high satisfaction of patients and their family caregivers.
High satisfaction
“Providers’ perspectives are that patients can safely stay in the comfort of their own homes to receive high-quality care continues to be reinforced through evidence,” Freedman said. “Clinicians who operate these programs and care for patients are also highly satisfied with their experiences. In fact, many clinicians report this patient-centered approach enables them to rediscover their love of medicine.
“Plus, hospital-at-home programs consistently attract experienced talent – specifically in nursing – and can reduce clinician burnout,” he added.
Finally, on an institutional level, hospital-at-home programs represent a tangible, actionable example of care model transformation, Freedman said.
“Health systems know they cannot continue to deliver care in traditional ways,” he noted. “Our aging population with higher utilization and lower reimbursement will continue to stretch systems beyond capacity. They simply cannot build and hire their way out of this current reality. Hospital-at-home and care at home more broadly represent a viable path to helping to better serve the community.
“There are two categories of health systems with hospital-at-home programs: established providers and those with more nascent programs,” he continued. “The former, characterized as systems who’ve reached an average daily patient census of about 15 to 20, where programs achieve cash flow positivity, are seeing many, if not all, of the benefits described.”
Bed capacity has improved, patients are enjoying high-quality care, and providers are becoming increasingly innovative in how to provide that care, he added.
Other care-at-home models
“Many of these systems are also expanding the foundational chassis established by their hospital-at-home infrastructure to other care-at-home models and use cases, including observation at home, emergency services at home, post-acute care and broader chronic condition management programs,” Freedman explained. “The economies of scale in using resources, technology and logistics for other home-based care models alleviate what might otherwise be challenging economics.
“Health systems that have developed and executed robust business cases are leaders in this space, and systems such as Mass General Brigham and Advocate, reaching ADCs in the range of 60 and 100, respectively, are paving the way for others,” he continued.
Less mature health systems are in a different position. For them, the actual practitioners within the model, including physicians, nurses, paramedics and operations personnel, among others, are fierce advocates; however, a number of forces have impeded progress.
“First, these health systems have not built the business case and designed or implemented their program accordingly,” Freedman explained. “Additionally, these efforts are a ‘side of the desk,’ and many health systems lack dedicated personnel, have unclear objectives, and feature ad hoc planning and logistics. In essence, these health systems have not built for the ADC they want; they’ve built for the ADC they have.
“Second, many of these providers focus on selected conditions and have not thoroughly assessed the potential for their broader patient population,” he continued. “Conditions such as CHF, COPD and community-acquired pneumonia are terrific use cases for lower acuity patients. However, the capabilities associated with supporting these patients are equally useful in supporting other patient populations, including post-operative patients, patients with more complex conditions, and even post-transplant patients.”
Organizational culture an impediment
Finally, the biggest obstacle health systems face is organizational culture.
“The systems that make a concerted effort to build trust in the program through constant communication and education are always more successful than those with a ‘build it and they will come’ mentality,” Freedman said. “Driving program design from a clinical point of view versus solely a business point of view is critical, as is taking a nimble approach that constantly evaluates successes and failures through a rapid and transparent appraisal process.
“Health systems that actively manage change are now seeing patients requesting services at home, and clinicians wanting to provide care, acute and otherwise, in the home setting,” he continued.
The hospital-at-home “movement” is at an inflection point. The data supporting the viability of the model is highly favorable, and it is real. While academic studies should continue to study the use case and its many facets, research supports a more mainstreamed approach that is not a series of pilot programs.
“Assuming general acceptance of the increasingly evidence-based concept of hospital-at-home, there are numerous tangible actions that can be taken by providers, regulators, payers and technology vendors to accelerate the broad adoption of hospital-at-home,” Freedman said. “A long-term extension of the CMS waiver – including permanent provisions – would bring much-desired stability to planning, operations, and, with the promise of reimbursement, economics.
“Many commercial payers will take their cue from CMS and develop both fee-for-service and risk-based reimbursement schema for Medicare Advantage and commercial plans,” he continued. “Even with reimbursement at something less than parity, these reimbursement sources will provide the critical mass of confidence necessary for providers to go all in.”
Program refinements
In addition, as with any new or existing care model, there will always be required program refinements.
“Logistics management remains a significant challenge, and many of the largest hospital-at-home programs still struggle here,” Freedman observed. “Logistics for acute care on an actual hospital floor are challenging enough. Imagine applying all that’s required in a facility to someone’s home.
“Then apply the additional complexities of traffic, weather, technology set-up and support, and so on,” he added. “It’s a large lift, and there are a variety of vendors who understand they can provide their expertise to address this complexity.”
Finally, there are a number of operational questions that remain open.
“For instance, the original CMS waiver requires all hospital-at-home patients be admitted via the emergency department or transferred from the hospital floor,” Freedman concluded. “In many situations, the former is an extra logistical step, it’s not patient friendly, and a broader patient population may benefit if they could be directly admitted from other locations, such as urgent care, or via their primary care doctor.”
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