Waitlist problem needs action now

When a health crisis sends someone to the hospital, the best-case scenario is that the patient will receive expert care, get better and go home. That’s what usually happens.

But sometimes patients improve enough to leave the hospital, but also require continuing treatment, intravenous antibiotics, say, or wound care. The necessary treatment doesn’t require the highest, most expensive, level of care, but is too complicated for the patient to manage on one’s own at home. Or, in the worst-case scenario, the patient has no home.

Hospitals try to place these patients in less expensive facilities to complete their recoveries, but too often these transfers are rebuffed — not necessarily for lack of beds, but because the patients are on Medicaid or Medicare and insurance reimbursements won’t cover the actual cost of their care.

Add in the fact that half of these patients suffer mental health problems along with whatever put them in the hospital in the first place, and it’s easy to understand why this problem — known as waitlisting — remains persistent, affecting more than 7,000 patients a year, or about 7.3 percent of all those hospitalized in Hawaii in 2011.

The need for solutions is urgent, including higher reimbursements for health care providers, more community-based health and social services for the mentally ill, and better training for unpaid family caregivers.

On average in 2011, wait-listed patients spent a week longer in the hospital than they needed to, and acute-care facilities took the financial hit — to the tune of nearly $63 million. These net losses reflect the fact that hospitals kept the patients but were not fully reimbursed for the level of care delivered, says a new report by the Hawaii Health Information Corp., which reviewed hospital discharge data from 2006 to 2011.

Although the average time these patients spend awaiting appropriate placement has fallen since 2006, the overall number of patients affected has not — in fact, it’s risen 11 percent. This trend is especially worrisome given that the average age of wait-listed patients in 2011 was 70, the risk of being wait-listed increases significantly with age, and folks over 65 are projected to comprise nearly a quarter of Hawaii’s population by 2030.

Another red flag: Patients with mental-health problems account for 49 percent of all wait-listed patients in Hawaii and remain hospitalized longer than any other class of patient, other than newborns with serious health problems. The HHIC report rightly highlights the need for community-based resources for patients whose poor mental health means they can’t take care of themselves, even after the immediate health crisis is over.

The report belies the conventional wisdom that waitlisting stems mainly from a lack of long-term care beds or other rehabilitation facilities. Paying for the care is the deeper problem. The availability per day of beds in long-term care facilities increased 300 percent across all Hawaii counties, yet hospital discharge waitlists persist. Care homes can’t afford to accept patients for whom they will not be fully compensated.

Hospitals can’t afford this burden either. Overall, the report said hospitals statewide suffered a total net loss of $388 million caring for wait-listed patients from 2006 to 2011, four out of five whom had a government insurance plan as the primary payer. Medicare, the federal insurance plan for those over 65, accounted for two out of three.

Given Hawaii’s aging population, this is a problem that could quickly grow far worse unless the federal and state governments, insurance companies and health-care facilities of all types work together toward solutions.