Portside

A couple of weeks ago, a good friend found herself in the emergency room at one of our world-class hospitals, the Brigham and Women’s Hospital in Boston. After emergency surgery, the medical team decided to admit her for at least another day to monitor her recovery.

What she encountered next was something out of a makeshift battlefield hospital, as rendered by Hieronymus Bosch. There were no beds available in the patient rooms, so “admitted” patients were being stashed in beds laid end to end in the emergency area. 

A bit of delay getting a bed is not unusual. But in this case, there were seriously ill admitted patients in 73 beds crammed into the emergency area. 

They had no privacy, and many were not masked. The beds wound around an overwhelmed nursing station, where a couple of nurses were mainly dealing with new patients. This makeshift field hospital was so large that it was sectioned off into subareas that had been given Boston street names (my friend was in the Exeter Street area), so that family and physicians could find them.

What the hell?

In exploring the deeper causes of the backup, you encounter a story of multiple, cascading failures of our health system. And no, it doesn’t have a lot to do with COVID overload. There are few patients hospitalized with COVID.

The immediate cause is a shortage of skilled nursing facilities, rehabs, and home care options into which still-impaired patients can be released. So patients are kept in acute care hospitals because there is no place else for them to go. 

This means that the normal process of beds opening up, as patients are discharged, backs up and bogs down. This is completely at odds with deliberate incentives in Medicare and private insurance plans to get patients released from expensive acute care hospitals as soon as medically feasible.

There are approximately 1,200 such patients currently occupying hospital beds in Massachusetts. In December, according to the Massachusetts Health & Hospital Association, 44 percent of hospitalized patients awaiting discharge to a skilled nursing facility were waiting for 30 days or more. They were basically in residence at a hospital, taking up scarce beds at the most expensive venue for care. And hospitals do not have rehab staff.

This mess is a vivid example of how reliance on commercialized health care with piecemeal regulation has failed and backfired.

Dig deeper, and there are the multiple causes of this mess:

There is a severe shortage of slots in skilled nursing facilities. Much of this is driven by a shortage of staff, mostly nurse aides, known as certified nursing assistants (CNAs). To be precise, there were an incredible 6,900 unfilled vacancies.

Why the staff shortage? The biggest single reason is that the work is hard and the pay stinks. A CNA typically earns between $18 to $21 an hour. Given Boston rents, this is not enough to live on. Many people trained as CNAs are working at other jobs. Many others working in nonclinical jobs at nursing homes could be trained as CNAs if the pay were decent.

This staffing shortage, in turn, has caused at least 20 skilled nursing facilities to close since the start of the pandemic; there are now 3,000 fewer beds in such facilities available than in 2020. Many nursing homes that are open are running at about two-thirds capacity and not accepting new patients, due to staffing shortages. Their business model calls for them to operate at capacity, so they are losing money and at risk of closing.

In addition, consolidations and mergers have cut the total number of inpatient hospital beds. These include the ongoing collapse of the Steward hospital chain, which converted a nonprofit Catholic health system to a for-profit one and then ran short of operating money after being milked by a private equity fund owner.

Another prime cause is the evil of Medicare Advantage, the privatized, for-profit system that leaches off Medicare. As the Prospect has reported, Medicare Advantage pretends to increase coverage. But because Medicare Advantage programs are so intensely “managed” to deny needed care, they are great when you are well but not when you are sick. 

While conventional Medicare provides 20 days’ coverage in a skilled nursing facility at no cost to the patient and another 80 days with a co-pay, Medicare Advantage plans often refuse to pay for post-hospital nursing care at all, according to a report by the HHS Office of Inspector General. The Mass Health & Hospital Association’s own report puts insurance denials for skilled nursing care as the top cause of the crisis.

A further problem is that health plans often don’t pay for case managers. An elderly patient facing discharge from a hospital, with multiple conditions, often complicated by dementia, is not competent to manage her own case.

When a hospitalized patient cannot safely go home, three options are a skilled nursing facility, a rehab, or home care. All are short of staff, largely because of profiteering and inadequate pay. 

Incidentally, the Republican policy blueprint for 2025 includes a suggestion to make Medicare Advantage the default option for all seniors coming into the program.

Yet another problem is the shortage of physical therapists, key staffers in rehabs. A decade ago, most licensed physical therapists had B.A. degrees. Then, their professional association, in order to raise pay, launched a successful lobbying campaign to require doctoral degrees. Result: a PT shortage.

Jessica Pastore, the director of external communications and media relations for Brigham and Women’s Hospital, responded to my questions in an extended email, pointing out that there is only so much that the hospital can do, but that they have actually cut waiting times for inpatient beds by 33 percent over the past year. Their strategies have included better coordination with nursing homes and home care options, as well as improved discharge planning.

The system is now so bad that its structural failures affect even the most privileged among us.

Where might some real system-wide progress be made? Most long-term nursing home patients are on Medicaid, which pays nursing homes at a far lower rate than Medicare. Even at capacity, nursing homes financed by Medicaid are barely in the black. During the pandemic, emergency federal and state aid financed extra help for nursing homes, provided that much of it would be passed along in higher wages. That aid is now finished. It would help if Medicaid paid at the Medicare rate, with the increased reimbursement earmarked for wages.

We also need real leadership from Gov. Maura Healey. Three weeks ago, the Mass Health & Hospital Association, working with Blue Cross and the state’s secretary of health and human services, Kate Walsh, came up with a palliative plan that will help only marginally. Blue Cross will streamline approvals for nursing homes, and nursing homes will stay open weekends to process admissions. Other insurers were not party to the deal; and in an indication of sheer cynicism, Steward Health Care was. 

Gov. Healey needs to make better, and better-targeted, state reimbursements a budgetary priority. SEIU Local 1199, representing nursing home workers, argues that the solution is both better pay, training, and reimbursement, and also incentive bonus payments for nursing homes that score well on staffing and low turnover.

This syndrome is simply not a problem in nations with universal health systems. Ours is a systemic failure in the broadest sense. Think of it as a supply chain crisis. It won’t be fixed piecemeal solely by better pay and more training for CNAs, though that would sure help. It certainly won’t be fixed by adding more refined incentives for cost containment, which has been the obsessive focus of health policy for decades.

The shortage of post-hospital facilities and the backup effect on acute care hospitals can be fixed only in the context of a universal system, which includes planning at every level. That means planning for facilities, for needed levels of health professionals, their training, and their compensation. 

This mess is a vivid example of how reliance on commercialized health care with piecemeal regulation has failed and backfired. Single-payer, long the goal of progressive reformers, is only part of it. We also need de-commercialization and comprehensive planning, which is only possible in the context of a universal and noncommercial system.

At 4 a.m., with no prospect of a room in sight, my friend gave up on the Brigham field hospital, and decided to risk her health and go home. She is a professional, married to a doctor. They figured that if anything really bad happened, they could go back to the ER. 

In sum, the system is now so bad that its structural failures affect even the most privileged among us. Some rich people get boutique medicine for their outpatient needs. But Brigham and Women’s is where Boston’s elite go for quality inpatient care. If that’s a mess because of deeper systemic problems, there is no place to buy your way out. 

My friend, as it happens, has long been a single-payer advocate. But as the systemic failure compromises the health of well-off conservatives as well as progressives, maybe that will provide some momentum for change.

Note: This piece is about Massachusetts. The problem is national. A follow-up article will look at trends nationally and federal policy.

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Robert Kuttner is co-founder and co-editor of The American Prospect, and professor at Brandeis University’s Heller School.