It's a good time for healthy realism in how we think about healthcare outside of hospitals.
For many technologists, insurers, strategists and others several feet removed from daily patient care within hospitals, no healthcare setting has drawn more intrigue in recent years than the home. Digital health or care delivered remotely in the home is often upheld as a healthcare experience patients universally prefer, a groundbreaking solution to bend the cost curve, and the future for a growing portion of health needs.
Forecasts and analysts predict a bright future for virtual or home healthcare. The projections are often delivered with some enjoyment in the irony that we already live in healthcare's solution for the future, or a full-circle reminder that medicine was primarily delivered in the home in the 1800s.
But if reality checks haven't hit yet, now might be time for "healthcare everywhere" enthusiasts to embrace healthy restraint. One state helps show why.
Massachusetts has long been a bright spot for U.S. healthcare. It enacted its own healthcare reform in 2006, dubbed Romneycare, that aimed to increase access to health insurance coverage. Massachusetts has the lowest uninsured rate in the nation — 2.4%, the latest figures show, compared to the national average of 8%.
About 7% of Massachusetts adults report not having a healthcare provider, which is about half the U.S. average and the third-lowest rate of healthcare detachment in the country. The state is right around the U.S. average for hospital beds per 1,000 people — 2.29 compared to the national average of 2.35.
The list could go on with figures and stats that paint a rosy picture of healthcare in the Bay State. Its health insurance coverage, median household income, social determinants of health and other factors consistently lift Massachusetts toward the top — if not to the very top — of every state ranking for health and healthcare.
All of this is to say that when healthcare problems come to a head in Massachusetts, it sends a signal that something is complicated enough to defy one of the most sophisticated healthcare systems in the country. Such is the case right now, as monthslong boarding problems in Massachusetts hospitals intensify, with the state health department declaring parts of the state "high risk" due to hospitals operating at max capacity.
Three regions of Massachusetts are operating in Tier 3 of the state's crisis framework designed during the COVID-19 pandemic, meaning hospitals are required to meet frequently to share bed availability and there is a possibility of facilities scaling back elective, non-urgent procedures and services.
Postponement of elective care and surgeries presents immediate challenges for patients and significantly impacts hospitals' financial security. The two-month suspension of nonurgent, elective operations in early 2020 cost a single academic health system 42 percent of its net revenue for five months, according to a 2021 study by the American College of Surgeons.
Unlike the care disruptions hospitals experienced in early 2020, the capacity constraints faced by Massachusetts hospitals today are not simply because more people are sick. Winter flu and virus season does bring higher patient volumes, but boarding is the more pressing problem at play. Growing numbers of patients who are ready to be discharged to a post-acute setting are stuck in hospitals' inpatient beds because there are not enough openings at rehabilitation facilities, long-term acute care hospitals, skilled nursing facilities or assisted living residences.
The Massachusetts Hospital Association released a count in December that showed more than 1,000 patients awaiting discharge to post-acute care settings. That count was up from July, when 755 patients were awaiting discharge. In some cases, patients who require specialized post-acute care services wait weeks or even months to find an appropriate bed or service. Last summer, of the patients awaiting a long-term care bed, nearly half had dementia diagnoses; a fourth had diagnoses of behavioral health conditions.
The problems in Massachusetts are likely similar to those experienced among hospitals in other states, but Massachusetts' advanced data reporting system is capable of measuring boarding in near real-time. Furthermore, despite the state grappling with an influx of migrants, the issue of sheltering appears separate from hospitals' inpatient, discharge and boarding problems.
Boston is one of the regions in Tier 3 right now. Its largest hospital, Massachusetts General Hospital, is experiencing an unprecedented capacity crisis.
"While hospital overcrowding has significantly affected patient care for many years, COVID-19 and the post-pandemic demand for care has escalated this challenge into a full-blown crisis – for patients seeking necessary emergency care, as well as for staff who are required to work under these increasingly stressful conditions," Dr. David F.M. Brown, MGH president, said in a January news release out of the hospital.
"This crisis is most acutely felt in our ED, where patients wait hours for an inpatient bed. Put simply, every day between 50 and 80 patients spend the first night of their hospitalization in the ED, which is not an appropriate or therapeutic environment for anyone and contributes significantly to clinician burnout and frustration," Dr. Brown said.
MGH has 1,045 licensed beds and serves as both an internationally renowned academic medical center with some of the most medically complex patients in the state and as the community hospital of choice for large parts of Boston and surrounding cities.
The hospital is hitting many levers to shore up capacity. It is seeking approval from the state to add 94 inpatient beds to its existing campus once construction of a new care facility is complete. (State officials originally rejected the hospital's request to add more beds in 2022, citing cost concerns.) It opened a new Patient Transfer and Access Center in 2023 to unite clinical experts and bed placement specialists to work in coordination, and also established a Discharge Lounge that lets staff on inpatient floors facilitate earlier discharges and open beds to other patients — about 125 per month — 60 minutes sooner on average.
MGH is also leaning into home healthcare and has built one of the strongest programs for it in the U.S. "Mass General Brigham Home Hospital is one of the largest and most established services of its kind in the country, where eligible patients receive acute-level hospital care from trusted providers in the comfort of their own home," the hospital noted in its communication about steps taken to reduce capacity constraints. The eight-year-old program treats 25-33 patients per day and has the capacity for 40 beds, with aims to one day reach 10% of inpatient capacity.
But home healthcare is no guaranteed replacement for post-acute healthcare, which is where Massachusetts is hurting badly. Twenty-five nursing homes closed from the start of the COVID-19 pandemic in 2020 to February 2023, with four more abruptly closing early last year, McKnight's reported.
A rule enacted in May 2022 from the state Department of Health prohibits more than two residents per room in long-term care facilities, which some say was a contributing factor to nursing homes closing and exiting the state. Any sort of policy change affecting post-acute settings stands to further complicate resources and staffing for the industry. Nursing homes make up the one setting that has not seen an employment rebound since COVID-19; as of June 2023, employment in U.S. nursing homes was 6% lower than pre-pandemic levels.
The capacity problems unfolding in Massachusetts are layered, concerning and a strong reminder of the brick-and-mortar paradox that health systems face. Many healthcare thought leaders and industry voices have spent a great deal of time, attention, resources, and hypothetical thinking on care delivered in homes, retail clinics, smartphone screens and other ordinary or lower-acuity settings. And while gazes are held 10 years ahead, hospital and post-acute bed capacity for vulnerable patients has only grown more tenuous. The limitations of healthcare beds are more immediately harmful today than the promise of technology is immediately helpful.
In a November survey of NEJM Catalyst Insights Council members — clinicians, clinical leaders, and executives at healthcare organizations around the world directly involved in care delivery — 61% said their organizations are planning to renovate existing health care buildings and 51% said they will build new buildings, with capacity needs, improved patient access and better throughput being the most common drivers for the capital plans.
"For as long as I can remember, there has been a need for more hospital beds," Andrew Ibrahim, MD, professor of surgery, architecture and urban planning, and vice chair of health services research at the University of Michigan, said in the NEJM Catalyst report. "Even with the increased focus on preventative care, a shift from inpatient to outpatient services, and the transition to digital care models, we still have a shortfall."
Curiosity, excitement and creativity toward the tools, capabilities, and technology that will help care for patients in the future shouldn't be neglected to solve current-day problems. Instead, it would be reassuring if futurists shorten their runways and focus just as intensely and enthusiastically on the next one to three years as they do when discussing the next 10. The messy middle.
And while we're adjusting parameters, greater inclusion of the medically complex, chronically ill and aging is needed. The vulnerable are too often brushed to the sidelines when virtual, AI-assisted, remote or digital healthcare delivery are upheld as the primary answers to healthcare problems. These are tools that represent one form of healthcare access that is appropriate for a segment of the population, and nothing more than that.
Talking about the future is easy. Fixing the present is hard. Massachusetts has long been a leader for U.S. healthcare, and how its current capacity problems are addressed and resolved are worth a close study.