How Medicaid Policies Keep Patients Stuck in the Hospital for Months
A new study offers clues about solutions to breakdowns in care
We've all heard horror stories of patients facing long wait times abroad due to rationing in single-payer healthcare systems. It’s also happening here in America – under Medicaid – according to a new UCSF study.
Most patients with severe traumatic brain injuries (TBI) are discharged a few days after being admitted to the hospital. But some of them stay there for months. The reason isn’t that they’re too sick to leave; in fact, they’re well enough to be discharged. A team of physicians led by Dr. Anthony DiGiorgio, neurosurgeon at Zuckerberg San Francisco General Hospital, set out to understand why.
The researchers find that the patients with extremely long stays share three characteristics: They have minimal home support, they suffer from more severe TBI, and they are on Medicaid.
Dr. DiGiorgio, who cares for patients just like those he studied, explained that the patients stuck in the hospital may have health insurance, but they don’t have access to care. “There was no institution or facility that would take them,” he says. That’s because there are just two rehabilitation facilities in the city of San Francisco that take in TBI patients on Medicaid, and they don’t have enough room for all the patients who need their services.
The reason more rehabilitation facilities don’t want to take in such patients is that Medicaid reimbursement is insufficient. Medicaid pays a flat fee per day that often doesn’t cover the facilities’ costs. And because those patients don’t have a safe and supportive home environment to go back to, they risk spending the rest of their lives in a long-term care institution, which is financially unfeasible for facilities.
Meanwhile, keeping patients in acute care hospital beds comes at a high cost to California taxpayers, and it reduces capacity for other patients who need hospital care.
This issue is reminiscent of the United Kingdom’s infamous bed-blocking crisis, whereby one in seven acute hospital beds is taken up by a patient who is well enough to be discharged. Some have been hospitalized for more than nine months. The issue there is that those patients are supposed to receive home health services, but there aren’t enough social care workers to take care of them at home. Why? Social care worker pay isn’t competitive.
In the UK as in California, inadequate payment policies are leaving patients stuck in hospitals. Dr. DiGiorgio has recommendations to fix California’s Medicaid program. For starters, a transition from fee-for-service to managed care can alleviate the situation, and an initiative called CalAim is helping to bring it about.
Ultimately, though, the growing Medicaid rolls are resulting in shortages of care for beneficiaries. Something has to give. Medicaid is a welfare program for low-income Americans, but as of July, it covered 90 million Americans – over one in four. That’s due to the Medicaid expansion, which gave Medicaid coverage to tens of millions of adult Americans without dependents or disabilities, and the fact that states are all but barred since the pandemic from reviewing enrollees for continued eligibility due to the ongoing public health emergency. And there’s also a growing number of people who rely on Medicaid for long-term care.
Medicaid should return to being a safety net for those who are most vulnerable and in need of assistance. Many of the people who enrolled into Medicaid thanks to the expansion were previously able to get coverage through employer-sponsored insurance. As for long-term care financing, empowering Americans with tax-advantaged savings options could prevent people from needing to seek Medicaid coverage at the end of life.
Dr. DiGiorgio and his team are going to conduct further work that will help them identify policy solutions so the most vulnerable patients have access to timelier care. Their findings will have implications not just for California but for Medicaid programs across the country.