Every day in the state’s dozens of hospitals, miracles happen, lives are saved — victims of gunshots and horrific crashes will live to tell their stories. Every day people are cured of illnesses that were once fatal.
But those emergency departments are also overwhelmed. Acute care hospitals are operating at 94 percent capacity, and many patients occupying those hospital beds are just as stuck as those trying to access emergency care because they can’t get a bed in a rehab or nursing facility.
Two problems are at the heart of this vicious cycle of dysfunction. First a mind-boggling worker shortage, which makes those beds hard to staff. The second is an insurance payment system that, according to Governor Charlie Baker, is stuck in the ’60s, when it was created, and doesn’t provide the incentives to reduce demand on emergency departments in the first place.
“Most of the money we spend is after people get sick,” Baker said following his testimony to the Health Policy Commission on Nov. 2. “We aren’t doing, in my view, anywhere near enough to keep them healthy in the first place.”
Too many of those who do get sick end up in hospital emergency departments. As the Globe’s Kay Lazar reported, that has become such a long, frustrating experience that many leave without treatment.
At Mass General Brigham, the state’s largest health system, the number of walk-aways averaged 6 percent for patients seeking care from July through October — a level three times higher than the figure that used to worry officials. It’s a figure that worries Dr. Michael VanRooyen, chairman of emergency medicine at Brigham and Women’s Hospital.
“There’s been pretty good evidence that shows that people who leave without being seen are equally as ill as those coming into the hospital,” he told Lazar.
Emergency department “boarding” — keeping patients who really require in-patient care, especially those experiencing a mental health crisis, in the emergency department — is not a new story. But conditions are getting worse.
“Thousands of health care positions are unfilled at the same time patient volumes are increasing, a dynamic that has created severe capacity pressures at Massachusetts hospitals,” according to a recent report by the Massachusetts Health & Hospital Association.
The report noted an “uptick in emergency department demand, inpatient and ICU admissions” and “a lack of available beds in other care settings,” such as rehab facilities to which patients would ordinarily be discharged, are part of the “spiral.” Nursing homes are also experiencing “historic highs” in unfilled jobs.
“Delayed care during the pandemic has led to sicker patients who need longer stays — adding pressure on a depleted workforce,” the report said.
How depleted? The MHA put the figure at about 19,000 vacancies in the state. Baker noted that’s “not counting the Steward health care system, which would probably add another 5,000 vacancies to that number.” Steward’s numbers were not included in the MHA figures.
On any given day, one in four emergency department beds are occupied by patients awaiting behavioral health care services, Baker said, citing the MHA report, adding that as many as 400 behavioral health beds “are currently offline not because they aren’t licensed, not because they aren’t available, but because they aren’t staffed.”
The crisis is real and it’s measurable and it can’t be fixed overnight.
A mental health parity bill passed by the Legislature and signed by the governor in August went into effect Nov. 8. In addition to mandating the presence of mental health professionals in the emergency department, it attempts to expand the pool of available providers by creating an interim licensure level of licensed supervised mental health counselors who can be reimbursed by insurers for their services and be eligible for state and federal grant and loan forgiveness programs.
A Health Policy Commission poll of a range of health care providers also found many were developing their own workforce pipelines with local schools along with their own certification programs.
The MHA, in its “call to action,” proposed extending the scholarship and loan forgiveness programs that are part of the mental health parity bill to the entire health care system. It also suggested an “AmeriCorps-type” program where new entrants into the health care field could receive tuition assistance. And the group suggested launching a statewide campaign to “encourage entrance into health care careers” — essentially establishing on a statewide basis that school-to-work pipeline that larger hospital systems are developing on their own.
And, as a reflection of the world we now live in, the MHA is asking for comprehensive workplace violence prevention legislation that would carry enhanced penalties for patients or visitors who attack health care personnel.
Of course, as Baker, a former head of Harvard Pilgrim Health Care, indicated, the future of health care really is about keeping people well and keeping them out of hospitals and emergency departments by expanding primary-care services. The governor twice filed legislation — in 2019 and again in March — aimed at requiring providers and insurers to increase spending on primary and behavioral health care by 30 percent over three years. The proposal played to rave reviews in the health care community but was largely ignored by the Legislature.
On Jan. 5, the issue of how to break the cycle of dependency on an overburdened system of emergency care and restructure the delivery of health care becomes Maura Healey’s problem. She could do worse than to follow the path Baker tried but failed to pursue.
Editorials represent the views of the Boston Globe Editorial Board. Follow us on Twitter at @GlobeOpinion.