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A few years ago, the Portland-based health policy researcher John McConnell recalls, he started hearing about a problem. People in mental health crises were going to emergency departments around the nation. And then they were getting stuck there, often for several days, as they waited for a proper care bed to open up.
Emergency departments are often loud and chaotic, and even if a patient gets a room while they wait, there’s a good chance it has no windows. This, it was clear to McConnell, was an unsuitable place for a suicidal or depressed young person to be holed up. But it was hard to get a national picture of the issue—at least, he says, until a large tranche of Medicaid claims data from 2022 emerged.
His resulting study, published today in the journal JAMA Health Forum, found that the problem is indeed massive. Of all the Medicaid-enrolled young people who went to a hospital emergency department for a mental health crisis that year, he and his colleagues found, more than 1 in 10 had to wait in the emergency room for more than two days before a proper bed opened up. This means tens of thousands of kids had that experience in 2022 alone. And in a way, he says, the study undersells the problem.
“The way that we defined ‘boarding’ was pretty generous,” says McConnell, director of Oregon Health and Science University Center for Health Systems Effectiveness. “We said three days or more. So this is not like a 48-hour stay. This is a long stay.”
Another notable finding was the variation between states. In Florida the problem occurred in 25% of ER visits, compared to just 5% in New Mexico. Oregon came in the middle of the pack, at just over the U.S. average of 11.9%.
McConnell suspects a few forces at work. One, he says, is rising levels of mental health issues, especially among adolescents, many of whom end up seeking emergency aid. For example, the number of kids requiring a psychiatric consultation in the emergency department of OHSU’s Doernbecher Children’s Hospital tripled between 2016 and the last calendar year, from 150 to 453, said Rebecca Marshall, an OHSU psychiatrist, in the university’s report on the new study.
In this context of rising demand, McConnell said, health systems have not kept pace. And for all the money flowing into behavioral health, he says, the care remains fragmented, with inadequate structures of accountability.
“There’s no single group that’s accountable,” he says, adding that in Oregon in particular, he thinks the community care organizations that run its Medicaid program could more directly take point on the matter, and be incentivized directly to get better results.
“Sate-level policies—including an assessment of the continuum of care that includes inpatient and residential beds, subacute beds, non-ED crisis support, and accessible outpatient care—could play a key role in reducing boarding and its impact on youths and their families," the study says.
