Washington hospitals have made a number of headlines recently. The state's hospitals lost $1.75 billion in the first half of 2022. Multiple health systems promised employees raises of 20 percent or greater. Understaffing led a Washington nurse to call 911 to assist her emergency department. And hospitals are considering cuts to travel staff.
"Our situation is in fact worse [than in other states]," Cassie Sauer, CEO of the Washington State Hospital Association, told Becker's. "And also, we're willing to talk about it."
Ms. Sauer has served five years in her position. All hospitals in Washington state are members of the not-for-profit trade organization, she said. The hospitals discuss quality and safety and share best practices.
But state laws and regulations have handcuffed healthcare, according to Ms. Sauer.
Hospital capacity fails to keep pace with population
Washington's population has grown significantly in recent years, but its hospital capacity has not. The state's tight certificate of need law has restricted facilities from expanding, which has led providers and residents to view healthcare differently. By way of analogy, Ms. Sauer said if one has a bad back in a state with a number of good surgeons, that person gets back surgery — whereas if one has a bad back in Washington, that person is sent to yoga.
Hospitals and health systems are short on staff for the beds they do have, in part because the state does not invest sufficiently in nursing education, Ms. Sauer said. The number of nurses graduating from Washington schools has not grown in a decade, she said, adding that because the state is not a part of the Nurse Licensure Compact, it is difficult for out-of-state nurses to work there.
The Washington State Nurses Association, for its part, opposes the Compact for being a "flawed, rigid, one-size-fits-all approach to nursing licensure," David Keepnews, PhD, BSN, the association's executive director, said in a statement shared with Becker's. "We don't believe that joining the Compact would ease the staffing crisis in Washington. Many Compact states continue to face staffing problems. Washington already processes licensure applications from out-of-state nurses within a matter of days."
Long-term care challenges clog system
Washington hospitals are also short beds because a "dramatic" amount of difficult-to-discharge patients have clogged the healthcare system, Ms. Sauer said.
During the pandemic, Washington lost 2,000 to 3,000 long-term care beds, according to Ms. Sauer. The state was especially restrictive regarding long-term care facilities during that time; if one patient tested positive, the entire facility would halt admissions, leading to lost revenue. Additionally, pay for long-term care workers is low in Washington, which makes it hard to staff the beds that are available, Ms. Sauer said. In part, patients are backed up in the hospital system because there are not enough long-term care facilities to take them.
But even if there were enough long-term care beds, state laws have made it difficult to send patients there, according to Ms. Sauer. In every other state, when a patient is incapacitated, their next of kin can decide to move them from a hospital to a long-term care facility. But in Washington, which recently reinterpreted the applicable law, a power of attorney or court-appointed representative is required to do this.
Ms. Sauer said CMS is "baffled" by this reinterpretation, which is backlogging care in the state's already overwhelmed hospitals. A legal memo Ms. Sauer shared with Becker's confirmed, "The commentary to the regulations makes it clear that [CMS] did not intend to require a formalized process for determining an individual’s representative and would look to state law regarding recognition of surrogate decision-makers. CMS rejected requiring the formalized approach that HCS has now adopted, stating: We are not requiring in this rule that an authorized representative be chosen using a formal process, such as a court appointed guardian, or the execution of a power of attorney."
Even though the WSHA has spoken out against this reinterpretation, nothing in Washington has changed, exacting a toll on hospitals' finances, according to Ms. Sauer.
When hospitals cannot discharge patients to long-term care facilities, it costs them, Ms. Sauer said. The state pays little for long-term stays — only a few hundred dollars per day, if anything, which is not enough to cover the physicians, housekeeping, food and other elements of patients' care. In addition, a patient who stays longer than necessary causes the hospital to miss revenue from other patients.
The state also has low Medicaid payment rates despite expanding Medicaid as far as possible under federal law, Ms. Sauer said.
"Hospitals have lost money hand over fist taking care of Medicaid patients in Washington state," according to Ms. Sauer.
Preparing for what's to come
If circumstances do not change, more than 50 percent of the state's acute hospitals might file for bankruptcy by 2023's end, Eric Lewis, CFO of the Washington State Hospital Association, said in an Oct. 4 press briefing.
Ms. Sauer, meanwhile, had three recommendations to help hospitals in the state regain their footing.
First, Washington hospitals are looking for additional Medicaid payments from the state. Second, hospitals are focusing on moving difficult-to-discharge patients through the system more efficiently through incentive payments to long-term care facilities and asking the state to accelerate its approval processes for aid. Finally, Ms. Sauer said, hospitals need to wean themselves off "phenomenally expensive" travel staff.
Some Washington health systems — including UW Medicine, Swedish Health Services and Seattle Children's — are raising pay for nurses.
"They are choosing to do it to retain staff," Ms. Sauer said, "and the hope is, the tradeoff is, that higher wages for existing staff will lead them to need fewer travelers."
Swedish aims to raise wages for 7,200 workers by 21.5 percent by July 2025, according to a news release shared with Becker's. "I am proud that we are significantly improving wages to support our caregivers and aid our retention and recruitment in a highly competitive market," R. Guy Hudson, MD, CEO of Swedish Health Services, said in the release.
UW Medicine also said its pay increases will aid in recruitment and retention efforts.
"The new agreements are historic and provide some of the largest incremental pay increases we have ever negotiated. These increases provide competitive compensation and will help us recruit and retain the staff required to deliver outstanding care to our patients," the health system said in a statement shared with Becker's.
To foot the extra cost — which amounts to 20 percent salary increases over the next few years — UW Medicine is taking additional steps, according to the release. It has implemented Mission Forward — "an initiative that will include steps to address capacity and staffing constraints and restore financial stability while supporting our patient care, educational and research programs" — and requested funding from the state for under-reimbursed services it provides, such as safety-net care and increased staffing costs.