UMass Memorial Medical Center was near a breaking point.
On many weekdays in the past year, the Worcester hospital’s occupancy rate hit 100 percent or more. Admitted patients sat in the emergency department for an average of 17 hours waiting for a bed.
And with capacity stretched thin, UMass Memorial was denying transfer requests from other facilities at far higher rates than before the pandemic.
The solution: In June the hospital asked the state for permission to renovate a nearby former skilled nursing facility it had bought the previous year and add beds to its existing campus. The $143 million plan, which was approved by regulators last month, would add 91 beds, an increase of 16 percent, most at the newly acquired site.
Capacity constraints aren’t just a problem in Worcester. Last year, Brigham and Women’s Faulkner Hospital in Jamaica Plan got the OK from the state to add 78 inpatient beds. Boston Medical Center is waiting for a decision on its request to expand by 70 beds.
The expansions come even as hospital patient volumes have been declining for years, both in Massachusetts and nationally.
The number of people discharged from Massachusetts hospitals fell from 120 per 1,000 residents in 2001 to 102 in 2020. The decline, which accelerated with the pandemic, is driven by a mix of factors, including higher numbers of outpatient surgeries and procedures, technological advancements, and efforts to reduce readmissions within 30 days of a discharge. State data through June 2022 show an ongoing decline in discharges.
Still, hospitals are as full as ever because staffing shortages at skilled nursing and rehabilitation centers have left patients staying in the hospital longer. Capacity at some hospitals has been further reduced by staffing shortages.
Some experts worry about the long-term cost ramifications of adding more beds, as hospitals usually find ways to fill the beds they are able to staff, whether by lowering the threshold for admission or having less incentive to discharge patients quickly.
“The thing with adding beds is they are kind of permanent,” said Meredith Rosenthal, a professor of health economics and policy at the Harvard T.H. Chan School of Public Health. “We do know that in the long run they drive demand. There’s some debate as to how big the effect is, but without doubt, if you build beds, you will get more admissions.”
Certain hospitals might have the justification to add more beds — building capacity to serve lower-income populations or meeting a regional or community need. But the state currently doesn’t have a comprehensive plan to address hospital capacity. Instead, state agencies look at projects as they come, through a lens of containing cost and whether the growth of one provider would hurt the services of another.
“We need an authoritative set of answers that take into account the uncertainties and are the best we can come up with collectively,” said Dr. David Blumenthal, a former Obama administration health official and the president of the Commonwealth Fund, a nonprofit research group. “That’s the purpose of planning.”
But others say statewide planning of hospital capacity isn’t optimal since hospital markets are local.
“Each project is looked at individually, along a number of criteria. One of which is patient need,” said Kathleen Carey, a professor of health economics at Boston University School of Public Health and a current member of the state’s Public Health Council, which reviews hospital expansion requests. “A lot of things are looked at. But the way to think about it is local.”
Hospital executives say they have more than enough justification to add more beds.
“What we’re trying to convey is we have a problem taking care of our current patients who are here,” Michael Gustafson, president of the UMass medical center, said in an interview. “This is current patients, and current demand, in Central Massachusetts.”
Gustafson told state regulators at a hearing in November that UMass Memorial would still need to expand even if the discharge issues were fixed.
But Saint Vincent Hospital in Worcester opposed the UMass Memorial expansion. Saint Vincent said it has dozens of beds available and suggested UMass wasn’t being efficient with its beds, whether due to poor patient flow, delays in testing and treatment, or other factors.
“There is a capacity challenge, yes, but if all the existing currently constructed beds were open, and if UMass was able to solve some of its efficiency crisis, the capacity crisis could be solved,” said Carolyn Jackson, CEO of Saint Vincent Hospital.
Gustafson contested the idea that Saint Vincent beds were the same as those at UMass, saying UMass was a larger system able to deliver more intensive services.
For example, UMass has a level one trauma center and air ambulance services, which Saint Vincent does not. The health system also said its patients’ length of stay was shorter than peers when adjusting for patient illness. While UMass had seen a drop in discharges over the pandemic, the hospital said demand remained elevated for medical and surgical beds specifically, which the hospital will add with this latest project.
Like UMass, Boston Medical Center said capacity challenges lay behind its own bid to expand, with the hospital routinely seeing more than 95 percent of its beds occupied.
Dr. Alastair Bell, president of the Boston Medical Center Health System, said the hospital had tried other measures before asking the state for permission to grow, including partnering with other organizations to keep people out of the hospital.
“Increasingly, it has felt like as much as we’re trying, we’re not able to fulfill our mission without adding more capacity,” he said.
The hospital noted in its application that despite pandemic declines in its discharges, volume was expected to return, and the aging of the population and prevalence of chronic disease across BMC’s patient population would raise demand.
State leaders appear interested in planning for the future. House Speaker Ron Mariano proposed legislation last session that included changes to how the state assesses some hospital expansions. He noted that the hospitals that expand are often teaching hospitals rather than community hospitals.
“I do think the Department of Public Health has to become more of an objective participant and more of a forceful participant in this whole debate,” Mariano said
Leaders from the state’s health care watchdog agency, the Health Policy Commission, also voiced a desire to partner with state agencies to assess broader needs.
“There is an opportunity for not just the HPC but the state generally to think longer term about health planning and where capacity is needed,” said David Seltz, executive director of the Health Policy Commission. “To date, many of these examinations have been done on a case-by-case basis by each individual expansion. There needs to be a longer-term view here. Perhaps now is the right time to do that.”