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Modern Healthcare - Opinion: Discharge delays are another sign of a broken healthcare system

9 Oct 2023 7:43 AM | Matt Zavadsky (Administrator)

An excellent insight into one of the primary drivers of ED delays and boarders in the ED.

At the recent American College of Emergency Physicians (ACEP) Summit on ED Boarding, the inability to discharge inpatients was a major driver highlighted. This is exacerbated by the paltry economic model for post-discharge providers, including ambulance service.

As an example of how economics and payment reform drive this process, I recently received a phone call from the Executive Director of one of the largest Medicaid MCOs in the DFW metroplex. He said he had 5 inpatients waiting for ambulance trips in Dallas (not MedStar’s service area), and he could not get any agency to transfer the patients out. He went on to explain that the cost of the inpatient facility care was significantly higher than if the patients were to be transferred to the post-discharge facilities. We discussed the low Medicaid reimbursement, and EMS shortages due to the staffing and economic crisis as the likely reason he could not find a provider and suggested that it may be in his economic interest to offer a higher reimbursement for the services to facilitate the ambulance transfers – which he said he could and would do.

Not also the opinion that payment reform could help patients get the right care, in the right setting, avoiding preventable hospital visits. The EMS profession has been promoting that change for years, since currently, we are ONLY reimbursed for services by Medicare and most commercial insurers who follow the Medicare rules, if we transport a 911 patient to the ED. A perfect example of how payment policy drives clinical practice.


Opinion: Discharge delays are another sign of a broken healthcare system

Chris Van Gorder

October 04, 2023


August marked a milestone for Scripps Health and one of our patients. After two years and three months at Scripps Mercy Hospital San Diego, the patient was finally able to leave. The patient didn’t need to be in an acute-care hospital for that long; there was just nowhere else for him to go. With a severe behavioral health diagnosis and a county mental health conservatorship, he required transfer to a specific, locked level of care. But there was no space available. So he stayed.

His situation is not unique. Another patient has been at one of our hospitals for more than a year and a half waiting for a county bed. During that time, he has exhibited disruptive behavior, including multiple episodes of hitting and throwing objects at staff members.

We have a number of patients who have been in our hospitals for more than 500 days. Our longest-term patient has been here for 2 1/2 years. He is on a five-year wait list for a state psychiatric hospital, but open beds for transfers are extremely rare, with priority given to state criminal patients over those being boarded at hospitals.

If we cannot move patients out of beds when they are ready to leave, we cannot take in more patients. It’s as simple as that. So we face bottlenecks—acute-care beds occupied with patients we cannot discharge even though they are ready to leave, which backs up patients in the emergency department. That, in turn, backs up ambulances waiting to offload patients.

This problem exists at hospitals across the country. A survey conducted over a three-month period last year by the Healthcare Association of New York State found that the 52 responding hospitals accrued 60,000 avoidable bed days at an estimated cost of $169 million. A report by the University of California Davis Medical Center said it racked up more than 7,800 ABDs in 2019 at a total cost of $20.4 million. According to an Advisory Board 2019 report, 71% of hospitals have at least 500 avoidable bed days per 1,000 cases.

At Scripps Health, we record more than 33,000 avoidable beds days annually. That’s up from about 11,000 three years ago. Our daily average jumped from 30 in 2019 to 91 in 2023. Over that period, the annual costs we absorb have skyrocketed, from $16.7 million to $59 million.

This is a state and national policy failure—one of many involving regulations and unfunded mandates focused on hospitals. The real problems that need to be addressed are chronic and intentional underfunding and a focus on fixing parts of the system rather than the broader issues threatening hospitals. Piecemeal legislation and policymaking won’t get the job done.

At the urging of the American Hospital Association and hospitals across the country, Congress considered proposals in December 2022 to compensate hospitals for some of their avoidable bed day costs through a temporary Medicare payment adjustment, but to date, none of those proposals have advanced.

Several reasons account for why these patients have nowhere to go. In San Diego, we have just over 800 inpatient behavioral health beds, but we need more than 1,600. Many step-down healthcare providers might have beds, but are struggling with staffing shortages. And many facilities won’t take patients with Medi-Cal (Medicaid in California) or Medicare if there are better-paying patients, or they will only designate some beds for them.

California hospitals have not received an increase in Medi-Cal base rate reimbursements in 10 years. But while facilities downstream from hospitals can pick and choose which patients they take because the Emergency Medical Treatment and Labor Act does not apply to them, hospital emergency departments don’t have a choice. So the patients stay.

Increasing government reimbursement to cover the cost of care at hospitals, as well as at other providers such as home health, skilled-nursing and behavioral health organizations, would give patients a better chance of being accepted elsewhere when they no longer need to be in an acute-care hospital. Or maybe they would receive the proper level of care in the first place, keeping them out of hospitals altogether.

Avoidable bed days are another sign of a broken healthcare system. Hospitals should not be stand-ins for nursing homes or specialized residential treatment facilities. Hospitals are the most expensive setting for these patients. And they’re not the right medical setting.

This is an untenable problem that must be fixed, but that won’t happen until more people are focused on solving it at all levels: local, state and national.

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