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HPC research: behavioral‑health ED boarding rose into 2024; nearly 39% of mental‑health ED visits spent 12+ hours
Summary
HPC staff presented initial findings that emergency‑department boarding for behavioral‑health patients (12+ hours) increased into 2024, with nearly 39% of mental‑health ED visits meeting the commission’s statutory boarding definition; staff tied boarding to longer inpatient stays, post‑acute capacity gaps, and workforce shortages.
The Health Policy Commission (HPC) on returning to public session presented preliminary research showing emergency‑department boarding for behavioral‑health patients increased through May 2024 and remains a growing system‑wide problem.
Research lead Lauren Nudi told commissioners the HPC adopted the statutory definition used in Chapter 177 (Acts of 2022): boarding is 12 or more hours after being assessed in the ED. "By 2024 almost 39% of patients visiting the ED for behavioral‑health related problems experienced boarding," Nudi said, citing linked hospital case‑mix and all‑payer claims analyses used for the study.
Why it matters: Longer inpatient lengths of stay and a shortage of post‑acute placements are creating bottlenecks that back up patient flow into EDs, the presentation found. From 2018 to 2023 total inpatient stays declined while average daily census rose; behavioral‑health inpatient stays decreased (presenter cited about a 22% decline by category) even as occupancy climbed. The research identified that patients with very long stays (>30 days) grew from roughly 3.8% of bed days to about 9% by 2023 and account for about half of bed‑day growth since 2016; behavioral‑health diagnoses are prominent among those very long stays.
Data and definitions: The HPC used hospital case‑mix, inpatient observation and ED visit data linked to an all‑payer claims database to estimate time in ED, downstream care and payments. Staff emphasized limitations: available data capture total ED time but not the exact time a treatment/placement decision was made, so the 12‑hour measure approximates statutory boarding but may not capture finer decision‑time detail.
Who is affected: The analysis reported that boarded patients were more often children, covered by MassHealth, living in lower‑income communities, and from Asian, Black, Hispanic or other nonwhite racial/ethnic groups. Among patients who spent 12+ hours in the ED, about one‑third were discharged home (presenter cautioned that the data do not establish whether home discharge was clinically appropriate), roughly 30% were transferred to another facility and about 22% were admitted to inpatient at the same hospital.
Payments and follow-up: Staff reported higher average payments for patients who boarded and were discharged from the ED (commercial payers and MassHealth), and mixed inpatient payment patterns depending on payer; the presentation also found patients discharged from the ED (boarded or not) were more likely to receive additional services within seven days than patients with an inpatient stay.
Commissioner concerns and questions: Commissioners asked about payer differences, the number and share of beds lost after recent hospital closures, front‑door alternatives to ED care, and workforce effects. Commissioner McGregor pressed staff for payer‑specific length‑of‑stay comparisons and the percent of beds lost when hospitals closed; Nudi said staff would follow up with more detailed numbers. Commissioner Coughlin reported ED staff had not always seen the community behavioral‑health roadmap play out in practice and flagged reductions in case managers as a potential future driver of boarding. Vice Chair Cohen emphasized pursuing both 'front‑door' investments (integrated primary‑care behavioral services and crisis alternatives) and 'back‑door' capacity (post‑acute and inpatient beds).
Next steps: HPC staff said the report in development will include multi‑state comparisons, stakeholder input, spending analyses by payer and policy recommendations to the legislature. Staff also noted a newly launched statewide behavioral‑health referral and bed‑availability platform that may help reduce boarding, but said the commission sees the problem as multifactorial and likely to require coordinated capacity, workforce and payment interventions.
The HPC did not take a final vote on policy in this session; staff will incorporate commissioner feedback and release a full report to the legislature and the public in coming months.
