Headway made, challenges continue in Mass. ER boarding crisis

By Christina P. O'Neill
March 4th, 2023
Leigh Simons Youmans
Leigh Simons Youmans is senior director, healthcare policy at the MHA.

Despite the passage of a state law in 2021 to address the psychiatric patient ‘boarding’ problem in the state’s hospital emergency rooms, some patients wait more than a year to access specialized treatment, according to a weekly report issued by the Massachusetts Hospital Association (MHA).

The report, “Capturing a Crisis: Massachusetts Behavioral Health Boarding Metrics” gathers data from Massachusetts acute-care hospitals on weekly boarding and trending patient data.

It tracks patients who are waiting for a behavioral health evaluation, and those who have had an evaluation and are waiting for a bed. Information is broken down by patient age and geographic region and includes boarding in med-surgical units as well as EDs.

The MHA maintains that Massachusetts acute-care hospitals. EDs and med-surgical units are not equipped to handle behavioral health issues. This was a logistical problem before the COVID-19 epidemic and has only increased since. When hospital psychiatric units can’t discharge patients into Department of Mental Health continuing-care beds, those units are unable to accept new inpatient psych admits.

Three things contribute to the problem: Behavioral health acuity, availability of staff, and longstanding under-reimbursement for behavioral health care.

Leigh Simons Youmans is senior director, healthcare policy at the MHA. “Addressing the behavioral health boarding crisis has been a top priority for MHA and our members for many years,” she said. “These situations prevent patients from receiving the specialized care they need, while tying up beds for other patients in need of acute healthcare services. Massachusetts has made great strides to address the crisis in recent years as the rate of boarding has increased.”

Youmans noted that in the wake of the pandemic, both overall demand for psychiatric care and the acuity of patients presenting to hospitals with behavioral health needs have increased.

The pandemic only exacerbated the stresses caused by decreased access to community-based services, which help patients “manage their mental health needs before they end up in the sort of crisis that requires hospital-level care. The staffing and resource limitations facing these organizations often makes it difficult for them to maintain full access.”

Massachusetts hospitals are not alone in this dilemma – it’s a nationwide trend, Youmans says, commending the state’s efforts made so far to address it.

The state’s $4 billion COVID-19 relief bill signed into law in 2021, contained $110 million for loan forgiveness for a range of behavioral health providers, Youmans said, citing it as “a tremendous investment in the workforce, and we know its benefits will not be seen overnight. Healthcare providers are continuing to leverage this funding, as well as a range of other creative solutions, to build up the ranks of their workforce. This will be a major focus for MHA and our members for the foreseeable future,” she said.

As of August of last year, at least 568 licensed inpatient psychiatric beds were “offline” across Massachusetts, up from 362 offline beds in October of 2021, Youmans noted. According to MHA’s August 2022 survey, more than 1,300 staff would be needed to make all of these beds available. That includes 504 mental health workers, 472 RNs, and 88 social workers.

Another problem: Who pays for the hospital boarding? This was a major point of advocacy for MHA and its members, Youmans said. “Up until recently, hospitals were not comprehensively reimbursed as they cared for patients boarding in their facilities. Often, they were reimbursed for only one day of a patient’s stay, even if that patient ended up in a stay that lasted weeks or months.”

That changed in May 2022 when the state’s Medicaid program began issuing enhanced reimbursements for hospitals in these scenarios, she said. And last summer, the Massachusetts legislature passed a major mental health bill that requires commercial plans to reimburse hospitals for each day a patient boards. Youmans cited this as an important victory, providing facilities with additional resources.

Additional MHA recommendations include creation of a behavioral health rate task force; prohibition of clinical denials because of administrative or technical defects; study of administrative barriers such as Determination of Need; and reduction of continuum of care challenges that limit patient access to services.

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