As the BA.5 variant causes hospitalizations to rise in the city, hospitals might face a challenge in caring for Covid patients: other patients in the hospital who stay for too long because they don’t have a secure place to be discharged.
At SUNY Downstate’s University Hospital, staff has seen an uptick in Covid patients within the last two weeks. Most of the patients included in the count are patients being seen for Covid symptoms, unlike previous phases of the pandemic where patients there for other health concerns wound up testing positive, said David Berger, the hospital’s chief executive.
Omicron BA.5 accounted for 45% of the city’s cases as of June 25, the health department reports, just six weeks after the strain was discovered. As it has grown, hospitalizations have also climbed, though they have not surpassed levels seen last winter.
If Covid patients once again overwhelm emergency rooms, one of the strains hospitals could face involves patients who are staying for too long, including those with behavioral health issues and intellectual or developmental disabilities, because there is no safe space to return after discharge. Legally, a hospital cannot discharge a patient that doesn’t have a safe place to go. Issues with residential placement for certain groups means many people wind up “stuck” in hospitals for longer than necessary.
While things are stable for now, Berger said, he has seen staff strained while trying to care for Covid patients and those in overextended stays.
Overextended stays come at a high price. The Healthcare Association of New York State reported that between added specialty care, staff injuries or overtime, legal fees, advanced discharge planning and loss of revenue due to substandard turnover, keeping a patient who can’t go home can be enormously expensive, and Medicaid reimbursements might only give back a percentage of what the hospital has incurred.
Sarah DuVall, the director of behavioral health at HANYS, said there are many reasons why hospitals might not get reimbursed, including the fact that many insurers don’t cover non-acute care provided in acute settings like hospitals, such as non-emergency care forced to be delivered in an emergency room.
In recent years HANYS has seen an increase in its member organizations keeping patients with disabilities or behavioral health issues for inappropriate stays, patients who can’t legally be discharged because there is no safe place to return to, she added.
“They’re very upset about the situation–staff who are [supposed to be] taking off come in to help patients who are stuck, and then can’t get fresh air, or celebrate birthdays,” DuVall said. “Some patients take up three beds in ED or inpatient areas, so other patients can’t get timely help. The problem is so bad hospitals are starting to put together advanced discharge planning teams, to make sure that patients could have a safe place to go after discharge, and try to fix some of these problems.”
When a hospital absorbs the costs left over after Medicaid reimbursement, it makes it harder to perform regular operations, research, and improve quality of care, DuVall added. She said HANYS is looking at what it would mean to implement a state czar for coordinating care for people with intellectual and developmental disabilities, to begin curbing the problem.
While SUNY Downstate doesn’t admit patients for behavioral diagnoses, Dr. Berger said that keeping any kind of patient, such as one recovering from surgery, for too long costs the hospital. Regardless of how long a patient is there, the hospital is only reimbursed for the patient’s expected length of stay, which is determined by their primary diagnosis.
This is especially problematic for hospitals such as University Hospital that serve a high percentage of Medicaid recipients. University Hospital is reimbursed approximately 47% for its patients on Medicaid and Medicaid HMO and those who don’t have insurance. CMS subsidizes the hospital another 40% through its Disproportionate Share Hospital adjustment. This still leaves, always, 13-15% of the costs of an overextended stay for the hospital to absorb, Berger said.
Being forced to absorb these costs means the hospital is at a deficit. It can’t get new equipment or buy new buildings and doesn’t have a margin to pay for capital, Berger added.
The Centers for Medicare and Medicaid Services told Crain’s it only pays for medically necessary services to prevent waste.
“Federal law requires that all states provide reimbursement for only services that are medically necessary to safeguard against unnecessary utilization of care and services,” a spokesperson said. “Providers that participate in the Medicaid program must accept as payment in full the amounts paid by the agency plus any deductible, coinsurance, or copayment required by the plan to be paid by the individual, and cannot balance bill the beneficiary.”
The spokesperson added, “CMS takes seriously the allegation that individuals are staying in the hospital for longer than is necessary, and invites anyone with related information or examples to share them with their state Medicaid agency.”
Patients with intellectual and developmental disabilities remain in hospitals when they don’t have secure housing to return to–and many don’t. A recent lawsuit against the state’s Office for Developmental Disabilities alleges that the office has denied many people’s Medicaid Home and Community-Based Services waivers, which would allow them to live in OPWDD-certified residential programs covered by Medicaid. Instead, the plaintiffs in the suit feel trapped in institutions and hospitals. Advocates say the waiting list to get into residential placement is thousands of people long.
OPWDD’s recently released 5.07 plan outlines how it will use federal funding to increase staff wages and retention efforts, which it told Crain’s are the biggest challenge to providing enough staffed residential opportunities for its consumers. The office told Crain’s it has increased its housing voucher and indexed it to Fair Market Rent, invested in expanding supportive housing options, and is seeking a waiver amendment next year to expand the availability and flexibility of its current residential model. According to its data, in 2020 OPWDD received just over $4 billion in Medicaid payments for more than 30,000 fee-for-service recipients in certified residential housing. —Jacqueline Neber