The Uncertain Future of Hospital at Home Programs with Molly Gamble

Summary

Becker’s Healthcare Podcast

Episode Title: "The Uncertain Future of Hospital at Home Programs with Molly Gamble"

Air Date: September 30, 2025

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Episode Overview

In this episode, Becker's Healthcare Vice President of Editorial, Molly Gamble, delves into the uncertainty surrounding the future of CMS’s Hospital at Home waiver, especially as its expiration looms during a time of federal funding uncertainty. Gamble explores both the historical context and the current anxiety felt by health system leaders over the sustainability and financial viability of hospital-at-home care models.

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Key Discussion Points & Insights

1. Looming Expiration of the CMS Hospital at Home Waiver

• Urgency Around the Waiver (00:54–02:17):
  Molly Gamble highlights the intense worry among hospital leaders over the pending expiration of the federal Hospital at Home waiver by CMS. With Congress yet to act, hundreds of programs face crucial decisions about continuity (“...urgency here is that unless Congress acts before September 30, hundreds of hospitals will have to face some tough decisions about their programs...” — Molly Gamble, 01:21).
• The policy dilemma is not just a bureaucratic headache, but one that “feels like watching the future of healthcare hang by a thread” (Molly Gamble, 01:41).

2. Hospital at Home: A Brief History

• Origins and Growth (02:19–03:23):
  Hospital at home is not a new concept; it traces its origins back to the mid-1990s with Dr. Bruce Luff at Johns Hopkins, but it long struggled due to lack of Medicare reimbursement.
• The pandemic catalyzed its growth as CMS, using emergency powers, waived several conditions of participation in 2020, allowing hospitals to launch the Acute Hospital Care at Home program and unlocking reimbursement (~03:00).

3. National Adoption and Scale

• Stats and Spread (03:29–03:46):
  As of July 2025:
  • 400 hospitals across 142 health systems in 39 states have been approved to offer hospital-at-home care.
  • Despite national reach, programs are small, generally ranging from a dozen to 50 patients each.
• Funding Extensions (03:48–04:30):
  Congressional extensions have become increasingly short and last-minute (two years, then 90 days, then six months).
  • “There’s a lot of anxiety around... pins and needles, as some have described every extension. They feel as though they are holding on until the very last minute...” (Molly Gamble, 04:13)

4. Investments and Reluctance

• Financial Risk and Strategy (04:33–05:20):
  Some health systems have invested millions into the hospital-at-home model—acquiring equipment, setting up new staffing models, and implementing technology to support connectivity in patients’ homes.
  • However, another group of health systems remain reluctant, “not going to make that bet” until there is more assurance of long-term federal backing, resulting in a “wait and see” approach.

5. Implications if the Waiver Expires

• Potential Patient Relocation (05:21–05:49):
  Without an extension, patients currently receiving care at home may need to be moved back into hospitals—a reversal of the recent healthcare trend toward further decentralization:
  • “...the exact opposite of what we've talked about so long in healthcare, where we’re moving patients out of the hospital into the home. So this could be a really unusual situation where the very opposite occurs.” (Molly Gamble, 05:44).

6. The Bigger Picture: Future of Home-Based Care

• Fit within Care Delivery Transformation (05:50–06:35):
  Hospital at home was seen as a major step in migrating patient care out of high-acuity settings.

  • Leaders express confusion and frustration at the piecemeal approach to program extensions.
  • Programs show potential to reduce readmissions and improve outcomes, but financial ROI is still “under review.”
  • A five-year extension bill is pending, requiring a comprehensive cost-effectiveness study.

• Uncertain Trajectory (06:36–07:27):

  • “...what does this mean for any sort of care delivery that moves... into the home... this could be a pretty serious signal that it might be a slower walk to that happening than I think it might have seemed at the time.” (Molly Gamble, 07:14).

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Notable Quotes & Memorable Moments

• "This isn’t just a policy headache … it also just feels like watching the future of healthcare kind of hang by a thread."
  — Molly Gamble (01:41)

• “You have some that have made some serious investments in getting these programs off the ground. You have a whole other group... that until there’s more assurance from CMS and Medicare funding... are likely not going to make the investments and expenditures...”
  — Molly Gamble (04:47)

• “There will be patients moving from the home to the hospital, which is the exact opposite of what we've talked about so long in healthcare, where we’re moving patients out of the hospital into the home.” — Molly Gamble (05:44)

• “This could be a pretty serious signal that it might be a slower walk to [home-based care] happening than I think it might have seemed at the time.”
  — Molly Gamble (07:14)

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Timestamps for Key Segments

• 00:54–02:17 — Introduction of the waiver’s looming expiration and its significance
• 02:19–03:23 — Historical context of hospital at home
• 03:29–03:46 — Current spread and statistics
• 03:48–04:30 — Growing anxiety and shortened extension periods
• 04:33–05:20 — Investment dynamics and health system strategies
• 05:21–05:49 — Implications of waiver expiration for patients
• 05:50–07:27 — Mixed results, future prospects, mention of proposed legislation

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Summary

This episode offers a concise yet thorough examination of the precarious position of hospital-at-home programs as federal support hangs in the balance. Molly Gamble offers a reporter’s clarity combined with industry insight, framing the potential loss of the CMS waiver as both a setback for individual hospitals and a significant barometer for the pace of care-delivery innovation. Listeners come away with an understanding of both the promise and the challenges of moving acute healthcare into the home—and the significant policy and financial uncertainties that will shape that future.

Transcript

[A]

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[B]

Hello and welcome to the Becker's Healthcare Podcast. My name is Chanel Bunger. Today I'm excited to speak with Molly Gamble, vice President of Editorial Becker's Healthcare, who joins us weekly to share insights in the healthcare trend. She's keeping an eye on Molly. Thank you as always for joining me. Why don't you take it away and tell us about some of the things that you're seeing out there?

[C]

Yeah. Thank you so much, Chanel. I wanted to highlight something that I think amid this federal shutdown that is looming for the nation, there's one smaller piece of the puzzle that I think is worth highlighting in health care, and that's the looming expiration of CMS's hospital at home waiver. This is something that's creating a mix of anxiety and some frustration among health system leaders overseeing these hospital at home programs. I want to credit our reporter Giles Bruce, who's done some really great work here connecting with different hospital at home leaders across different health systems. And basically the urgency here is that unless Congress acts before September 30, hundreds of hospitals will have to face some tough decisions about their programs even in an interim period. If there is funding that is secured and this is extended, and in the near term, they might face some choices about bringing patients back into inpatient facilities who are currently receiving care in their homes. So for many leaders, which I think my comments will highlight, this isn't just a policy headache. And it certainly is a policy headache, but it also just feels like watching the future of healthcare kind of hang by a thread. So many hospital home leaders are really invested in this form of care delivery. So I want to just unpack. Chanel, if someone is not as deeply familiar with hospital at home, a couple of things here to keep in mind. You know, this form of care delivery isn't exactly new. It kind of has recency bias, where we heard a lot about it during the pandemic, but it dates back to the mid-1990s. The concept of it, at least it was developed by a geriatrician named Dr. Bruce Luff at Johns Hopkins. And for a long time, since the mid-1990s, it was quiet. It really struggled to gain traction, in large part because Medicare didn't reimburse for hospital at home. That changed in 2020 and the COVID 19 pandemic, when CMS used its emergency authority to waive several conditions of participation. And since the concept really came to fruition in the mid-1990s, there was a reason that hospital at home was quiet for so long. For decades, this model really struggled to gain traction, in large part because Medicare didn't reimburse for it. Then you have COVID 19, the pandemic 2020. This changes. CMS uses its emergency authority to waive several Medicare conditions of participation. And then you have it launching the acute Hospital Care at home program. And since that time, there are 400 hospitals across 142 health systems in 39 states that have been approved to offer hospital at home by CMS. That's as of July 2025. So that's the number of participants that are looking for September 30th for a decision to be made. I will say the programs are pretty small. You have some programs that it's a little bit more than a dozen patients currently being cared for in their homes. Others maybe about 50, 40 patients. So still relatively modest in the grand scheme of things. But this has been a tricky one because we've seen Congress extend hospital at home three times. The first one was for two years, the second one was for 90 days, and then the last, most recent was for six months. So you have the extension periods getting shorter and shorter. I think in the leaders that Giles is connected with, there's a lot of anxiety around pins and needles, as some have described every extension. They feel as though they are holding on until the very last minute to find out if this extension comes through, if the federal funding will remain from CMS to continue this work. And there's systems that have invested millions of dollars, Chanel, in this care delivery model. It takes different staffing models. It takes different equipment and technology to keep patients connected in their homes. So you have some that have made some serious investments in getting these programs off the ground. You have a whole other group of health systems that until there's more assurance from CMS and Medicare funding that they're not going to take that bet. It's been a bit of a wait and see where unless the government comes through and CMS comes through and committing to hospital at home for the long run, they're likely not going to make the investments and expenditures in getting these programs as built out as they could be. So that's where it lies with health systems. I think we will continue to watch as things unfold up until the 30th. I was interested to read in Giles reporting about these systems, basically having to decide if on the 30th the funding is not secured and it doesn't come through, there will be patients moving from the home to the hospital, which is the exact opposite of what we've talked about so long in healthcare, where we're moving patients out of the hospital into the home. So this could be a really unusual situation where the very opposite occurs. I think it's also something that when we talk about ambulatory expansion, moving patients out of high acuity settings, this was a big bet in doing that and scaling that and to see how it has been really extended in this piecemeal fashion. And now up until the very 11th hour, I think leaves leaders with a lot of questions when we talk about migrating patient care out of the hospital. This was a great example of doing just that. And it seems as though the results, it's a mixed bag. You've got systems saying that these programs have really improved. It can reduce readmissions, it can improve outcomes. But some note that those financial ROI still remain under review. There is a five year extension bill that's pending right now and that bill would require HHS to study the cost effectiveness of hospital at home, which is a key piece of information that is important. But it seems as though leaders are looking at this with a mixture of, like I said, anxiety. I think some head scratching. Chanel. And then I think in the long term, what does this mean for any sort of care delivery that moves not even into an ambulatory clinic or an outpatient site, but into the home, which again in 2020, 2021, 2022. So many healthcare conversations were rooted in this idea of that we would be moving closer to the home in the next five, 10 years. This could be a pretty serious signal that it might be a slower walk to that happening than I think it might have seemed at the time.

[B]

Perfect. Well, Molly, I want to thank you as always for joining me today and for sharing your insights on the Becker's Healthcare podcast. Always a pleasure. Thank you.

[C]

Thank you so much. Chanel.