‘Broken system’ behind Md.’s long emergency department wait times
Thomas Eagle’s heart rate was hovering around 39 beats per minute when his wife, Anna Palmisano, drove him to the emergency department at Johns Hopkins Suburban Hospital in October 2022.
He had COVID-19 and, while he lifted weights and exercised regularly, he was also 75 years old. Palmisano was worried. But after five hours passed and Eagle still hadn’t seen a doctor, they left the Bethesda hospital. They couldn’t wait any longer, they decided.
Eagle’s heart rate had returned to normal by the time he was able to make an appointment with a cardiologist, but Palmisano still shudders when she thinks about the choice they faced at Suburban.
“It was a terrible decision to have to make,” she said.
While long emergency department wait times are a problem everywhere in the country, they are particularly bad in Maryland. Besides Washington, D.C., and Puerto Rico, there’s no place in the United States where people wait longer to be seen.
Patients in Maryland spend 4 hours, 7 minutes, on average, from the time they arrive in emergency departments to the time they leave, according to federal data last updated in January. That doesn’t include patients seeking help for psychiatric or mental health reasons — a population that waits, on average, for about 6 hours, 40 minutes in Maryland.
For close to two decades, policymakers, health care experts and advocates in Maryland have been trying to figure out why wait times are so long and how to improve them. The results of the latest
investigation into the problem — conducted by a 28-member work group convened by the Maryland Hospital Association — were released in a report last month.
The report identified several root causes of the state’s long wait times, including a community health care system in desperate need of expansion and the dire shortage of behavioral health care options. It also recommended a buffet of policy solutions to improve the flow of patients in hospitals, from reforming prior authorization practices to addressing hospital capacity needs.
“There’s not one policy lever that we can pull,” said Erin Dorrien, the hospital association’s vice president of policy, who co-chaired the work group with Dr. Ted Delbridge, executive director of the Maryland Institute for Emergency Medical Services Systems.
In a statement responding to Eagle’s experience at Suburban Hospital, a Johns Hopkins Medicine spokesperson said the health system’s hospitals are operating at 90% capacity, which creates challenges in managing the flow of patients. However, the statement said, hospitals have processes to ensure that patients are continuously assessed while they wait to address urgent medical needs.
Palmisano, director of Marylanders for Patient Rights, also served on the committee, but unlike Dorrien, she didn’t leave the process feeling encouraged.
The hospital association initially planned to release the report in January — when the General Assembly’s 90-day legislative session began — but instead sent it to lawmakers on March 18, three weeks before the session ended.
Palmisano suspects the work group’s size slowed the process. She was frustrated that it was dominated by hospital executives and lawmakers, rather than front-line health workers. And, Palmisano said, the report suggested few immediate solutions. It didn’t make her optimistic the situation would improve anytime soon for patients or health care workers in Maryland.
“I have to tell you,” she said. “I have this vision of myself — it’s sort of a nightmarish vision — of it being four years from now, and I’m still sitting there in hearings.”
A long wait
Why do Marylanders wait so long when they go to emergency rooms? The answer — like most in the health care system — is complicated, according to the hospital association’s report.
Unlike urgent care centers, emergency departments aren’t allowed under federal law to turn
away people who are seeking help. Experts widely consider emergency department crowding a symptom of a broken medical system ill-equipped to care for patients, especially those who are low-income or otherwise disadvantaged.
Even though Maryland has three medical schools, access to primary care remains lacking. There are fewer than four primary care doctors for every 10,000 residents in Caroline, Garrett and Somerset counties, according to data from the Maryland Health Care Commission. In Baltimore — the jurisdiction with the highest ratio — there are about 13 for every 10,000 people.
About 6.5% of Marylanders don’t have insurance, which means they may turn to emergency departments for non-urgent conditions that could be treated by a community-based doctor or show up very ill because they don’t have access to preventive health care.
Americans are also sicker than they used to be, said Dr. Jeffrey Sternlicht, Greater Baltimore Medical Center’s chair of emergency medicine who served on the hospital association’s work group.
When Sternlicht started practicing emergency medicine about 26 years ago, most of his patients had low-risk illnesses and injuries.
“Now, we’re seeing the majority of patients coming in emergency departments way sicker — patients with multisystem problems, with complex diseases that require a lot more resources,” he said. “You’re seeing someone who has heart disease, diabetes, cerebrovascular disease and dementia.”
However, the number of hospital beds in Maryland declined from 12,000 to 11,300 from 2015 to 2021, according to the work group’s report. The state had 1.82 beds per 1,000 people in 2021 — the fifth
lowest in the country and below the national bed capacity of 2.38 beds per 1,000 people.
More beds don’t necessarily equate to shorter wait times. Washington, D.C., has the country’s highest number of hospital beds per 1,000 residents, according to an analysis from KFF, but it also has the nation’s longest wait time at 5 ½ hours.
But according to the report, several work group members said a lack of hospital beds in Maryland hampers the movement of patients from the emergency department. Delays in discharging patients — which often happen because there aren’t enough beds at skilled nursing facilities — make this problem worse, the report said.
When inpatient beds are filled, doctors respond by boarding patients who need to be admitted in the emergency department — a practice that increases how long others must wait to be seen.
The seven-day average number of patients boarding in emergency departments in late 2023 ranged from 300 to 670, according to data from the Maryland Institute for Emergency Medical Services Systems.
Boarding causes plenty of problems for hospitals, besides prolonging emergency department wait times.
It’s associated with delayed and missed care, as well as increased sickness and death rates — and higher rates of burnout for emergency department staff members, according to a study in the Joint Commission Journal on Quality and Patient Safety. Staffing shortages across the medical system contribute to long wait times, the report said.
The state’s behavioral health crisis also stresses emergency departments. Between 1970 and 2014, state psychiatric hospital beds declined nationwide from 70,000 to 40,000, Sternlicht said. There are
massive gaps in mental health care outside hospitals, too — from a shortage of spots in outpatient programs to a threadbare workforce.
“Everybody who works in health care wants access to care,” Sternlicht said. “We’ll all be patients one day. I’ll be a patient. And I don’t want to have to come to the emergency room and wait 12 hours because we’ve got a broken system.”
Fixing the problem
Despite Maryland’s long emergency department wait times, the state is doing some things right, according to the report and health care experts.
Legislation establishing a permanent funding source for the state’s 988 crisis helpline system is awaiting Gov. Wes Moore’s signature. According to the report, the 2024 state budget included $107.5 million to strengthen behavioral health care in Maryland.
Last summer, Maryland’s Health Services Cost Review Commission rolled out the Emergency Department Dramatic Improvement Effort — a data initiative that officials call “EDDIE” for short. Under the program, hospitals report metrics like emergency department wait times monthly and meet to share best practices.
Another recent move by the health services commission has been more controversial.
In December, it voted to include emergency department wait times among the metrics used in a reimbursement program that rewards hospitals for improving and penalizes them for poor performance. While the commission is working out the details of how to implement the change, under the vote, emergency department wait times will have a 10% weight in the calculation of hospitals’ overall performance scores.
“It’s definitely not intended to be punitive,” said Jon Kromm, the commission’s executive director. “The root cause drivers are numerous and complex, and we agree that a lot sit outside of the hospital. But we also know that hospitals can and have made strides within their walls to improve the length of stay.”
Many hospital leaders, including those at Johns Hopkins Medicine and Adventist HealthCare, oppose penalizing hospitals for high emergency department wait times. Hospitals have tried dozens of strategies to improve their emergency department operations, leaders say, but so much is out of their hands.
“Adventist HealthCare and other health systems have absolutely no incentive — financially, morally, encouraging and keeping our work staff in place, medically, legally — to keep patients in the emergency department any longer than they should be,” said Patsy McNeil, the system’s senior vice president and chief medical officer.
“Proposing a penalty on top of everything that’s being done to the best of our ability — with our nurses, our physicians and our ancillary staff working themselves to the bone to take care of these patients — is something that we wholeheartedly disagree with.”
The road ahead
In the association’s report, work group members recommended more than a dozen strategies for easing the flow of patients through hospitals and relieving strain on emergency departments.
They singled out two as top priorities: reforming prior authorization practices to be more efficient and finding ways to sustainably fund behavioral health services for people with mental illnesses.
Other priorities include encouraging urgent care centers to do more to attract and accept patients, increasing access to end-oflife care and community-based services, and lowering uninsurance rates. The work group also recommended workforce development efforts like reducing nurse and social worker licensure burdens and partnering with community colleges to increase the pipeline of licensed practice nurses and imaging technicians.
The report additionally recommended partnering with the Maryland Judiciary to review the state’s guardianship process and consider adding an “expedited health care limited financial guardianship pathway” to reduce barriers to care and help hospitals discharge patients more efficiently.
How to improve hospital capacity became one of the biggest sticking points in work group discussions. Maryland may have enough inpatient hospital beds overall, according to the report, but those beds are not distributed where population growth is rapid or demographics are changing. This leaves hospitals in some jurisdictions with bed shortages, the report said.
To tackle the hospital capacity problem, the report recommended studying the unique way that Maryland decides how much hospitals should be paid and determining how that model affects emergency departments. The report also recommended that policymakers consider modifications to the Certificate of Need program, which sets the rules for when a health care facility can add beds.
The solution to long wait times may sound intuitive — why doesn’t Maryland just add more beds to emergency departments or build more hospitals? — but it’s not that simple, said Dr. Joshua Sharfstein, the health services commission chair and former Maryland health secretary.
Much of the capacity problem exists because patients spend extra time in hospitals waiting to be transferred to a skilled nursing home, rehabilitation center or other health care facility, Sharfstein said. He’s open to considering all proposed solutions, he said, but “a solution has to be comprehensive in order to work.”
Ben Kaufman, a registered nurse and battalion chief of Montgomery County Fire and Rescue, said he understands that research shows building a bigger emergency department isn’t enough to reduce wait times.
But, he said, solutions are needed now.
“All the things that have to be done on the back end, in the upstairs of hospitals, to make sure patients have a place to go? That needs to be done,” he said. “But in the short term, we have to be able to improve our capacity to take care of patients.”