Baltimore is one of the country’s preeminent health care cities. Yet studies have shown that hospitals here as well as all Maryland hospitals have the longest wait times in their emergency departments for seven years running.
The legislature has put forth HB274/SB387 to find out why. SB387 proposes creating a task force to study the problem. The original bill recommended a task force consisting of one member each from the Senate and House of Delegates, a designee of the secretary of health, a representative from the Maryland Hospital Association, someone who actually works in an emergency department, and two patient advocacy representatives.
This group was to identify potential solutions. This is a good start. Subsequent amendments recommended by the hospital association proposed adding additional task force members.
While we should be concerned about Maryland’s high emergency room wait times, they are a symptom of a larger problem that affects the entire health care system, which is throughput.
One of the reasons patients are waiting in the ER is because hospitals cannot discharge their current inpatients to other care locations, such as rehabilitation, nursing or long-term care facilities. This is due to staffing shortages as well as insufficient facilities. Medical patients also wait too long to be seen for medical conditions because most hospital ERs are boarding patients for whom no inpatient beds are available.
Another reason for patients boarding in the ER is the lack of inpatient psychiatric beds. Behavioral health patients brought to the ER in crisis by the police or families may wait for weeks or even months for scarce beds to open in mental health or substance abuse treatment facilities.
Beginning in the 1970s, Maryland and other states began closing state-run inpatient mental health care facilities in favor of the creation of more outpatient facilities. While this was thought to be better for patients, not enough has been done in our communities to provide these outpatient alternatives to accommodate the growing need.
Patients with no reasonable alternatives must wait in the ER for an inpatient placement when they need treatment.
We should examine the alternatives for behavioral health treatment as well as care for patients with chronic or minor conditions who could be more efficiently managed as outpatients in the community, instead of in the ER. Maryland’s high rate of ER wait times further suggests that the proliferation of urgent care centers in the state has done little to alleviate the pressures on hospital ERs. The urgent care centers still send a percentage of patients to the hospital ERs.
Although many U.S. hospitals are having difficulty with staffing shortages and financial pressures due to the COVID-19 pandemic, Maryland is unique as the only state in the country that has piloted the “All-Payer Model.”
Under this experiment started in the 1970s, the Health Services Cost Review Commission (HSCRC) sets the rates that each hospital can charge for a procedure. Instead of having different rates for different payers (e.g., Medicare v. Blue Cross), the charge for the same procedure, such as a knee replacement, is the same for each payer as well as for patients without insurance.
The charge for a procedure does vary among hospitals, so that knee replacement may cost more at one facility than at another. And, unlike other hospitals in the nation, Maryland hospitals receive a global budget.
So even if volumes spike or costs rise (or fall), the hospitals’ compensation is mostly fixed. The goal of the pilot was and is to reduce Medicare costs and improve quality outcomes, and the HSCRC must report annually to CMS on the state’s progress. The HSCRC should participate in this committee.
We appreciate the legislature’s attention to the problems faced by our health care providers and encourage the committee to examine the system of care. This system starts with primary care for patients with minor or chronic conditions and greater use of outpatient facilities to care for patients, particularly those with behavioral health needs. This will ease the pressure on the ERs, which should not be viewed in isolation.
We support looking at the bigger picture as it will take stakeholders from the entire care continuum to address the problems affecting health care delivery, an important part of Maryland’s legacy and future.
Editorial Advisory Board member Arthur F. Fergenson did not participate in this opinion.
EDITORIAL ADVISORY BOARD MEMBERS
James B. Astrachan, Chair
James K. Archibald
Gary E. Bair
Andre M. Davis
Arthur F. Fergenson
Julie C. Janofsky
Ericka N. King
Susan F. Martielli
Angela W. Russell
Debra G. Schubert
H. Mark Stichel
The Daily Record Editorial Advisory Board is composed of members of the legal profession who serve voluntarily and are independent of The Daily Record. Through their ongoing exchange of views, members of the board attempt to develop consensus on issues of importance to the bench, bar and public. When their minds meet, unsigned opinions will result. When they differ, or if a conflict exists, majority views and the names of members who do not participate will appear. Members of the community are invited to contribute letters to the editor and/or columns about opinions expressed by the Editorial Advisory Board.