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CASUALTIES OF A FAILED HEALTH CARE SYSTEM  
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Robert Kuttner
February 6, 2024
The American Prospect
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_ Why even an elite Boston hospital can feel like a makeshift
infirmary in a war zone _

The Shapiro Building at Brigham and Women’s Hospital in Boston,
Steven Senne/AP Photo

 

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
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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
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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
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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
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& Hospital Association’s own report
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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
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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
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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
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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
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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.

* US Health Care; Commercialized Health Care; Steward Health Care;
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