It is an ideal time to advance the “acute care at home” model, says LDI Senior Fellow Austin Kilaru, especially if that means combining hospital services, recovery, and follow-up into one system that reaches into patient homes.

The pandemic launched a new Medicare program that let more hospitalized patients receive their treatment at home, because regulators allowed higher payments. But that momentum has stalled, with most hospitals declining to participate.

The current rules make the traditional model too costly and risky to build, especially for small and rural hospitals, Kilaru notes in a JAMA Internal Medicine Viewpoint, with LDI Senior Fellow Robert Burke, and colleagues. Better financing and more realistic regulations could create a revamped system.

An emergency physician and health policy researcher at the University of Pennsylvania, Kilaru offers a 10-point rundown of what we know about hospital-at-home and what can be done to create a system for the future.

1. Hospital-at-home works—and has for decades.

Hospital-at-home programs lower readmissions, complications, and costs, with evidence dating back 30 years. The model is proven, not experimental.

2. COVID policy jumpstarted programs, but their sustainability remains uncertain.

A Medicare waiver allowed equal reimbursement with traditional hospital care, sparking rapid adoption. But uncertainty over the waiver — and even a brief lapse — stalled momentum. Despite the hype, two-thirds of approved hospitals haven’t enrolled patients.

3. The biggest barrier isn’t demand, it’s startup costs.

Unlike building hospitals, which are funded as long-term capital projects, hospital-at-home programs must be funded through operations, making them risky and hard to launch, especially for smaller systems.

4. Payment is inconsistent across insurers.

While Medicare pays equally under the waiver, Medicaid and commercial insurers may not participate, creating financial uncertainty.

5. Current rules make programs too complex to build.

Hospitals must replicate nearly all in-hospital services at home (nursing visits, labs, imaging, pharmacy), which are costly and challenging to coordinate.

6. Simplify the model—focus on what patients actually need.

Allow flexible, lower-intensity versions (more virtual care, fewer in-person visits) instead of requiring full hospital replication.

7. Invest upfront, not just reimburse later.

Create payment models that cover startup costs, not just per-patient care, especially for rural and safety-net hospitals.

8. Align payers to support scale.

Bring Medicaid and commercial insurers into the model so hospitals can build programs that work across all patients—not just those on Medicare.

9. Build toward integrated, at-home care episodes.

Move beyond “hospital replacement” to bundled models that combine acute and post-acute care at home for better outcomes and lower costs.

10. The model carries huge potential, but also risks.

Hospital-at-home could transform care and expand capacity—but may increase disparities, strain caregivers, or even raise costs if used improperly.

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“Rethinking Hospital-at-Home Policy to Achieve Scale and Impact” was published in JAMA Internal Medicine on April 6, 2026. Authors include Austin S. Kilaru, Susan Landon, Felicia D’Souza, and Robert E. Burke.

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