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Medical Center in Maryland have been running a version of these programs for decades. But the federal government's willingness dur- ing the Covid-19 pandemic to offer flexibility to hospitals to accommodate patient surges opened the floodgates to industry efforts to dramatically expand these programs and make such crisis standards permanent in pursuit of profit. When the federal government declared a public health emer- gency (PHE) in March 2020, CMS granted hospitals blanket waivers to treat patients through temporary expansion sites. But in November 2020, CMS expanded that waiver to allow hospitals to treat acute-care patients at home. Most importantly, it suspended the normal requirements under its conditions of participation to receive Medicare and Medicaid reimbursements for round-the- clock nursing care to be provided on site to patients, and for the immediate availability of a registered nurse. According to a Dec. 7, 2021 New England Journal of Medicine Catalyst article, the "Acute Hospital Care at Home" program was developed with heavy input from industry players in just eight days. The waiver application form for "experienced" hospitals that have already treated 25 or more patients under such programs is literally two pages long. The waiver form for "inexperienced" hospitals is five pages long. The program requirements shockingly lack in-person assess- ments of patients. After an initial in-person history and physical is taken of the patient by a doctor or advanced practice provider, there's actually no requirement for any more in-person visits by a doctor or registered nurse. The program only requires two in-person visits per day, which can be fulfilled by an "MIH/CP," which basically stands for a paramedic. Everything else is allowed to be done remotely, through telehealth visits and monitoring through technol- ogy and video. Only two vital sign readings need to be taken per day. Most disturbingly, the program allows a 30-minute response time for patient emergencies, which can be met by calling the local 911 system. In a hospital, as nurses well know, providers can call codes and rapid response teams can be at a patient's side with spe- cialized equipment within seconds. There's no comparison. Elle Kruta is an RN at Mission Hospital in Asheville, N.C. She said when she first heard about these Home All Alone so-called "hospitalization" programs, she had a strong negative gut reaction. "No, no, no, no, and no, some more," said Kruta. "There is no substitute for human contact. You can feel the heat and cold of a person's body, you learn so much from touching a patient's abdomen. What does their breath smell like? Does it smell like juicy fruit gum? If so, you are already in trouble, you are in DKA [dia- betic ketoacidosis]." As long as hospitals met those minimal waiver conditions, they could bill and collect from CMS at exactly the same rates as if the patient were located at its brick-and-mortar hospital. CMS reim- bursement is considered key to the viability of these programs, since the agency is such a significant payer of health care services and pri- vate payers often follow their rules. Without the guarantee that Medicare and Medicaid would pay for these kinds of programs, the hospital industry has little financial incentive to pursue them. But the hospital industry views Home All Alone programs as a gold mine because it dramatically cuts one of their main overhead expenses: building, running, and maintaining physical hospital facilities. That's why the industry has shelled out hundreds of mil- lions of dollars to establish such programs. "A very significant part of the expenses associated with hospi- talization is fixed cost overhead, roughly 65 percent in most institutions," said Stephen Parodi, MD, a Kaiser Permanente executive, during a May 2021 virtual press conference announcing Kaiser and Mayo Clinic's $100 million investment in Medically Home, one of many companies springing up across the country that logistically supports these programs. "What if we move that patient to another site of care, where the overhead costs are much lower?" That site is, of course, the patient's own home. But residential housing does not meet the same stan- dards as a hospital facility, and lacks the backup power, water, and telecommunications infrastructure that's critical in case of emergency. These waivers exist, however, only because of the declared public health emergency and ostensibly would cease when it ends. That's why the hospital and affili- ated industries are lobbying heavily for either long-term extensions of these waivers or to make the waivers per- manent. In addition to the American Hospital Association and state hospital association trade groups, the main players have started the Hospital at Home Users Group, an organization to promote and lobby for the deregulation needed to expand these programs. In response to the industry's incessant lobbying, law- makers have proposed legislation at the federal and state levels to pave the way for these Home All Alone programs. For example, Wisconsin's governor in March signed a bill eliminating the sunset date for such pro- grams in that state, and in California, the state Assembly is considering a bill, AB 2092, that allows state hospitals to care for acute-care level patients in their homes as long as it has federal waiver approval and informs the California Department of Public Health (CDPH). Cur- rently, hospitals that want to run such programs are J A N U A R Y | F E B R U A R Y | M A R C H 2 0 2 2 W W W . N A T I O N A L N U R S E S U N I T E D . O R G N A T I O N A L N U R S E 13 "It is an insult to nurses, to the nursing and all medical professions, and even more worrisome, it is straight up dangerous for our patients."