The Rappaport Center addressed the realities of a healthcare system under strain last week with their panel discussion on the current crisis in Emergency Departments in Massachusetts hospitals, with renowned experts in hospital administration, healthcare regulation, and insurance gathered to explain the intricacies of providing patient care.
Moderated by Mary Beckman, former acting secretary of the Massachusetts Executive Office of Health and Human Services and a member of the Rappaport Center Advisory Board, the panel tackled the question of how emergency care and the healthcare system have been declining in efficiency. Although hospitals and the public health department have been working to fix problems within the system, as Amy Hoey, the president of Lowell General Hospital, put it, “it’s never been worse than it is today.”
Hoey emphasized that the inefficiency of the emergency department stems from the inefficiencies in the healthcare system, not its workers. The emergency department front door is by law open to everyone, but the “back door” tends to get clogged. As Hoey explained, the hospital should see 60-70 discharges per day, but even that number is often out of a doctor’s control. Discharges are often reliant on whether the patient has proper resources like at-home care or transportation. “As ‘stuck’ patients build up, we know we’re going to have problems on the front end,” Hoey said.
She pointed to three creative solutions that Lowell General has implemented, including working with an inbound coordinator to facilitate patient care between primary care physicians and the emergency department, working to provide mobile integrated health, and working to increase transportation for out-bound patients.
Limiting the number of patients coming into hospitals is important but challenging. To run smoothly, principles of queuing theory suggest that hospitals should be operating at 85 percent capacity, according to Dr. Ashley Yeats, vice president of medical operations at Blue Cross Blue Shield of Massachusetts and a former emergency department physician. However, for the past few years most hospitals have been operating at over 100 percent–sometimes even as high as 150 percent–capacity. But any attempt to change one part of the system can cause an unwelcome domino effect. “I could cancel surgeries in the ED, but that cuts an entire income stream as well as patient care, and cuts service lines in the hospital that can then fund the other services being provided,” Yeats explained.
Dr. Guy Fish, chief executive officer at Codman Square Health Center, broke down the complex system into a simple concept: supply and demand. In Massachusetts healthcare, effective change requires lowering the demand rather than simply raising the supply. “Why is the demand so high? What are ways to decrease that?” he asked. The cause behind the heavy demand may vary–from insurance plan limitations, to an inability to see a doctor during regular business hours, to serving patients from ethnic or cultural backgrounds in which the norm is to go straight to the ED when sickness hits.
In fact, the state of emergency rooms in Massachusetts is not the real problem, according to Dr. Robert Goldstein, commissioner of the Massachusetts Department of Public Health. Many patients with illnesses that end up in the ED should be seen in the office of a primary care provider, but despite being a city rich with extraordinary and specialized medical care–and a state that has the highest rate of insurance coverage–Massachusetts has the fewest primary care doctors per capita than any other state. Furthering the issue, Fish pointed out, is that only 5 cents of every dollar goes toward primary care.
Commissioner Goldstein focused on policy and regulatory tools that his department is deploying to tackle some of these problems. To expand the primary care workforce, for example, the department is implementing a recently passed law that allows the state to bring in foreign medical graduates and give them a pathway to licensure in Massachusetts without requiring them to complete a residency program. Another lever is to use the professional regulations for nurse practitioners and physician assistants to enlarge the scope of their work and give them more flexibility to provide primary care.
Whether it’s primary care, urgent care, or emergency care, each panelist summarized the situation in two words: It’s complicated. “If it were easy, we would have solved it a long time ago,” Yeats said. Organizations and hospitals are working tirelessly to find a solution, to deliver safe and effective care to those in need, to provide transportation to and from the hospital, and to build community behavioral health centers. Each panelist recognized the situation is bigger than an individual hospital or insurance plan, and collectively, they are working to build social support structures that deal with the source of the problem, not just the symptoms.