The CFO HaH Playbook: Survive Now, Profit Later (August Cover Story Excerpt)

CFOs need bold cost restructuring and strategic scale, to make Hospital at Home work.

Hospital-at-Home (HaH) promised to revolutionize healthcare delivery, freeing up beds, cutting costs, and keeping patients happier at home. But CFOs face a stark truth: without bold cost restructuring and strategic scale, the model’s financial foundation may crumble before it ever delivers on its promise.

The following is an excerpt from our August Cover Story. Read the full story here. 

The CFO Playbook: Survive Now, Profit Later

HaH discussions are often dominated by clinical voices, but CFO engagement is essential for scalable, profitable growth.

“Because it’s a new care setting, whenever I present on HaH, the audience is always clinicians—there are zero financial executives in the room,” says Tom Kiesau, chief innovation officer and leader of digital & technology transformation at Chartis.

A key lesson in UNC Health’s HaH program was the importance of building a “scalable and quickly scalable” model, because smaller programs with only 10–15 patients per day aren't sustainable long-term. UNC Health CFO Williams Bryant emphasized setting a clear path to reach at least 30 patients daily to maintain momentum and internal support. Strong executive and physician backing was also critical to success, as misalignment within leadership or clinical teams can stall the program’s progress.

“I can't imagine trying to implement a model like this without having strong physician support,” Bryant says.

While many health systems launch their own HaH programs internally, others contract with vendors to handle technology and even daily monitoring and in-person visits. For his part, Bryant recommends using external partners to launch the program but be ready to pivot when that partnership no longer adds value. He also urges CFOs to get straight with payers from the start.

"Get your payer relationships lined up on the front end," Bryant advises, noting that early assumptions about payer alignment didn’t pan out, which created financial and operational challenges.

Lastly, Bryant says, don’t treat it like a pilot.

“I think one of the mistakes that we made when we implemented it early on was we treated it like a pilot and kind of continued to treat it like a pilot,” he says. “I really do think you have to scale these programs from the start and almost over invest in your resources to be able to absorb the capacity, because what we're finding now is that our capacity is constrained.”

Mass General Brigham CFO and Treasurer Niyum Gandhi advises new HaH adopters to take the long view, avoid overengineering, and ensure strong leadership support. Financial sustainability shouldn’t be judged too early.

“Give it a time frame,” he says. “Treat it like a real commitment.”

Define clear clinical and financial outcomes and measure performance rigorously. Focus on delivering better patient outcomes, not just breaking even. Finally, leverage the collaborative spirit in healthcare: reach out to other systems for shared learnings.

“The competition isn’t the other hospitals,” Gandhi says. “The competition is death and disease.”

The Financial Future of HaH

The countdown is on. If the CMS waiver disappears later this year, so does the clearest path to reimbursement for most HaH programs. Without it, patient volumes could collapse, margins could vanish, and CFOs will be forced to choose between propping up a program with shaky returns or pulling the plug entirely.

“It's one of the most broadly adopted waivers in history,” says Kiesau. “It is now in the popular press. It's not even just healthcare press. It's in the Wall Street Journal.”

Some healthcare executives believe HaH programs are here to stay, regardless of the Medicare waiver decision, but there will be noticeable differences and bigger risk for some systems.

Gandhi emphasized that without the CMS waiver that is set to expire, the financial sustainability of HaH programs is at risk, especially for smaller health systems.

"If CMS stops paying for it, I think what we'll realize is a lot of scale programs will become subscale,” he says.

Medicare patients make up a large share of eligible admissions, so losing traditional Medicare coverage would significantly shrink patient volumes. Programs would then face higher administrative burdens and payer eligibility checks, straining operations and frustrating clinicians. Gandhi also highlights difficulties in negotiating with payers when care decisions are dictated by insurance rather than clinical appropriateness.

“We're hopeful that CMS has seen, as we certainly have seen, the value of this program both in terms of its ability to get great outcomes and have exceptional patient experience,” adds Bryant. “With this population compared to the overall population, we’ve seen lower readmission rates and higher patient satisfaction.”

Hospital-at-Home is not a short-term cost cutter. It’s a long-term capacity and care transformation play. The winners will be the CFOs who resist overengineering, scale deliberately, and make bold, sustained investments in infrastructure, workforce, and payer alignment.

In a market where beds are finite and capital is tight, this is the pivot that will decide who thrives.