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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. If you've needed admission to a hospital in the past few years, you might have spent hours, even days, in the emergency department first while waiting for a real hospital bed. Dr. Elisabeth Rosenthal, senior contributing editor at KFF Health News and former ER physician, wrote about the issue of emergency room boarding, as it's known for The Atlantic. We'll talk to her in a minute. In 2024, by way of background, her husband AndreJ was admitted to the emergency room, the emergency department, for complications from esophageal cancer. After 36 hours in the ED on a stretcher in the hallway, he finally got a bed "upstairs," which itself turned out to be an overflow area that lacked enough personnel. For the last months of his life, Rosenthal writes her husband's mantra became, "I will not go to the emergency room." One director of emergency medicine told her that hospitals now run like airlines and intentionally overbook in order to make money.

"The problem is in the way health care finance is structured," her source told her. It can increase the anguish of people who find themselves in emergency department limbo who may not get a bed or have any semblance of privacy. Worst of all, it can lead to some patients falling through the cracks, which, of course, can be not just an inconvenience but hazardous to their health.

Joining us now to discuss her latest is Elisabeth Rosenthal, senior contributing editor at KFF Health News and a former ER physician herself. She's also author of the book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back. This new piece for The Atlantic is titled, "A Barbaric Problem in American Hospitals is Only Getting Bigger." Dr. Rosenthal, welcome back to WNYC.

Dr. Elisabeth Rosenthal: Well, thanks for having me.

Brian Lehrer: Listeners, we want to invite you in on this as well to help report this story. For those of you who work in emergency departments or patients for whom this sounds familiar, we invite your stories as well as your questions. How has ED or ER boarding changed over the past five years? In particular, if you work in a hospital, for those of you who do, what are you noticing and how is it impacting your jobs and your patients? Nurses, nursing assistants, doctors, directors of emergency departments, anyone else relevant, help us report this story. 212-433 WNYC 212-433-9692.

Again, patients or caregivers of patients who've been to the ER, if you had a recent experience you'd like to share, we invite that from you, too. Did you spend many hours, maybe even a few days in the emergency department recently? What was that like? What would you like others to know about your experience that may help make things better? 212-433 WNYC 212-433-9692. You can call, or you can text. Dr. Rosenthal, as I said in the intro, you open the piece with your husband Andrej's mantra in the last months of his life, "I will not go to the emergency room." First of all, I'm sorry for your loss.

Dr. Elisabeth Rosenthal: Thank you.

Brian Lehrer: You write that you understood that his adamant rejection came because most prior visits had, as you write, "Morphed into extended trips into a terrifying medical underworld to a purgatory known as emergency department boarding." Tell us what boarding is and what the 36-hour experience was like.

Dr. Elisabeth Rosenthal: Well, boarding is if a patient goes to the ER, which is the front door of hospitals for every patient now, and it's determined they need admission. Then, the question is, okay, is there a bed available for that admitted patient on a ward? The problem is there are too few beds for the patients who need admission from the emergency room, particularly if they're older or sicker. We'll go into the finances of that later.

They park these patients like my husband, who had stage 4 esophageal cancer and was dying on a stretcher in the emergency room. Maybe you're in one of the bays, maybe you move to the hallway, maybe you move to an ER overflow area. Technically speaking, you're admitted. You have some physicians, a team upstairs who knows about you, who may be writing orders. If you say, "Hey, I need to use the bathroom," and remember, there are only two bathrooms for everyone in an emergency room, or, "I'm short of breath," it's very unclear who needs to respond to that.

ER physicians and nurses have complained bitterly about this for years. It existed to a smaller degree in the past, but it's just grown and grown, particularly since the pandemic. It's just awful. That admission you're referring to, my husband was confused. He was still getting treatment, and it was unclear if the cancer had gone to his brain, which it hadn't but he needed an inpatient evaluation and to get his mental status better. As you can imagine, this is a guy who was totally compos mentis the day before, and he was a little confused. Two days in the emergency room, stuck on a stretcher, rails up, as I said, not being able to get around, not knowing whether it's day or night, codes going on, alarms blaring.

By the end of the second day, he was convinced that the doctors were somehow in a conspiracy to get him, and I was their paid accomplice. I was like, "Why would you go back to something like that?" You come to an emergency room if you need admission because you're seriously ill, and what you get is not good medicine. I think ER doctors have been writing about this. The American College of Emergency Medicine has complained about it bitterly. I just wanted to show what it feels like to be a patient or the loved one of a patient going through this experience. It's awful.

I'm sure everyone says, "Oh, yes, I waited four days at this hospital," or, "I waited two days next to a corpse at this hospital." I think so many of us have experienced it, but we're not really near a solution, which takes a lot. It's not really only the hospital's fault, and certainly not the doctors or the patients or the nurses' fault. Everyone's trying to do their best in terms of the personnel, but hospitals are partly to blame, but we have to talk about the larger system to really understand what's going on here.

Brian Lehrer: When you push to move him to a bed upstairs, as they call it, because emergency rooms are almost always on the ground floor, he was transported to what you describe as an ED overflow area on a former labor and delivery floor. You write that, "It was kitted out with some of the trappings of an actual ward, such as real beds and bathrooms, but not the most important one, adequate personnel." From your article, you write that two people died in three days in that room. How widespread is this kind of improvised overflow arrangement?

Dr. Elisabeth Rosenthal: Oh, totally widespread. You're lucky if a hospital tries that solution because at least you're not in some hallway on the way to radiology for two days. You get an actual bed. It feels like a kind of, and I don't say this slightly, a warehousing of patients who have no hope, who are destined to die or have dementia. I think the most striking thing to me in the days he was on that ward was I said, "Gosh, his sheets haven't been changed in three days." The Nurse looked at me and said, 'Well, there's the linen card." I'm like, 'Oh, okay, is this what we're paying $2,000 a night for?" They did eventually come and change it for me, but it was pretty nightmarish.

Brian Lehrer: Let me take a few stories from listeners, and then we'll get into more of the structural reasons that it's like this and what you think can be done about it. Let's go first to Tara in Metuchen. Tara, you're on WNYC. Thank you for calling.

Tara: Oh, thank you for taking my call. Can you hear me okay?

Brian Lehrer: Can hear just fine, Tara. Thanks for calling.

Tara: Awesome. A couple of years ago, my daughter had a mental health crisis, which brought her to the ER at a very good hospital near us. She was 16 or 17, so just took her to the pediatric ER but really she was by far the oldest patient there. Because it was a mental health situation, she was put in a special room off in a corner of the emergency area. The room had no windows, out the door, you could not see any light from outside. She was stuck there for, I forget, three nights or maybe four, waiting for a bed to open up in another facility, a proper mental health facility. During that time, she was just basically rotating between screaming and shouting and being medicated and sleeping and awake.

It was completely horrific for her, for us who were with her. Again, she couldn't get outside for a breath of fresh air. She couldn't see the outdoors. She really could not leave her room. I'm pretty sure she has PTSD from that experience. We probably do too. She pretty much now refuses to go to the emergency room if needed. It was not a good experience.

Brian Lehrer: Tara, thank you very much. Disturbing as that is, it's probably useful for people to hear it from you in that way. Let's go to another patient with another story, actually a story of one way that he's getting around the kind of thing we've been describing here so far. Jack in Westfield, you're on WNYC. Hi, Jack.

Jack: Hi. Good morning, Brian. You're a national treasure. For your guest's consideration, my mother is an 85-year-old Alzheimer's patient, and so she's in assisted living. Whenever she has a fall, which has happened about six or eight times over the last year, she gets transported to the hospital, which is the standard protocol for the facility that she's in. They normally transport her to a Trauma I, North Jersey, very, very good hospital in a very wealthy part of the state. We have literally stopped having her sent there. We choose for the local community hospital, which is really not the best place for stroke care or cardiac arrest care, because the situation is just as your guest has described.

You get assigned to the orange section, location 5, or you're in the red section, location 2. You're there for 36 hours. It's very difficult to get information from the nurses and doctors who are working really hard. It's almost like the Port Authority bus terminal at rush hour. My siblings and I have decided for our sanity and for our mother's sanity, because there's no privacy and there's-- We just say, "You know what, let's go to the local community hospital where we know she's going to get a room. We know the PET scan of the head and chest is going to come back negative, and we'll get her back to where she lives as soon as possible."

Brian Lehrer: Jack, thank you for telling that story. Dr. Rosenthal, do you think that that's a way out for many people? Obviously, it depends what kinds of hospitals are available in any given area. Maybe people have an assumption that the larger big-name hospitals are going to be the places for better care. Maybe it is some of the smaller community hospitals, where people may not think they have as much to offer, that don't have this emergency room crowding or boarding issue. Or maybe Jack is a one-off, I don't know.

Dr. Elisabeth Rosenthal: No, I think he's pointing to an important hack. The problem is what do we mean by better care? The smaller community hospitals are, in fact, not the places that have big problems with ED boarding. It is the big, famous medical centers, the Level I Trauma Centers. If you're in a situation like I was, like Andrej was, where you're getting complicated cancer care at a particular hospital, that's where you have to go. Right?

If it's something simple, sure, you can go to the community hospital. You'll get a bed much quicker there. You may not have the expertise that's needed to be treated. I think we can talk about the reasons why it is these big, impressive hospitals that have the biggest problem.

Brian Lehrer: Well, let's talk about that. Listeners, if you're just joining us, my guest is Dr. Elisabeth Rosenthal, senior contributing editor at KFF Health News and a former ER physician who wrote about the issue of emergency room boarding, that is staying in the emergency room for many hours or even days before you can get a room upstairs, as they call it in a regular bed. Wrote about this for The Atlantic, and her article is called, "A Barbaric--" Barbaric is a quote that we're going to hear why in a minute. A barbaric Problem in American Hospitals is Only Getting Bigger.

The question of why you went back to your old colleagues to ask how this happened, an ER doctor at Boston's Beth Israel Deaconess, Adrian Haimovich, told you, "Everyone knows about this problem, and no one cares enough to do anything about it. It's barbaric." That's where the strong word in your headline comes from. What's your understanding of why this is the case?

Dr. Elisabeth Rosenthal: Well, it's really multifactorial. One thing, as we said in the story, is that hospitals run like businesses, right? That's what I've been writing about for 30 years. If you want to have beds available for ER patients, you don't want to run at 100% capacity. You want to run at maybe 90% capacity, so there'll be beds available. From the hospital's business standpoint, that view, an empty bed is a money loser, right? It's staffed, it's sitting there, you got oxygen, so you want to keep those beds full all the time. Now hospitals run at 100% capacity, or near it, if they can.

When I was in an emergency room physician, and this was now decades ago, if the hospital was full, they would cancel elective admissions. Now, no hospital does that, because those elective admissions that need beds, those are hip replacements, they may be a heart procedure. Those are big moneymakers. You want beds filled with people who need lucrative care, right? That's one reason why they're full all the time.

Another reason why it's so hard for the patients in the emergency room is if you're older or sicker or stage 4 esophageal cancer or any other cancer like my husband was, you can go to a bed, but you're not going to be a big money maker. You likely don't need anything that's a big procedure or an operation. You just need a tune-up and some evaluation. That's not very lucrative. It takes a lot of time because you have to schedule tests with radiology that may not be able to do them for three days. The more systemic issue is, even if those people are cleared to go home, there's an enormous shortage of rehab beds in this country.

They very likely can't just go home to their previous living environment if they've worsened or their condition has worsened. We don't have rehab beds. We don't have what we used to have, transition units, which help people who are lower-level care unit to transition out of the hospital. There's an enormous shortage of nursing home beds. That's a factor we have to deal with. Beyond that, even is, hey, if you need-- It's determined you need to go into hospice, which we were trying to arrange for my husband, you need to get insurance approval because your insurer may only have contracts with certain hospice providers, and that's a whole thing.

Then, if you're on Medicare Advantage, for example, they can say, "Oh, we're denying this transfer to rehab. Maybe we don't think you need it." You have to be in the hospital two, three nights in order to qualify. Then, they deny it. Then, the hospital appeals. Those patients can block a bed, producing no income for days and days on end. It's a complex problem that is solvable, but as Dr. Haimovich said, "Nobody cares enough to solve it."

Brian Lehrer: Let's hear another patient story. Tom in Manhattan, you're on WNYC with Dr. Rosenthal. Hi, Tom.

Tom: Hi. My experience is not as extreme as some of the other patients', but it just typifies what a standard situation is for someone. I'm a transplant patient, so I'm immunosuppressed. A transplant has a lot of sequelae, little things that happen, infections, and stuff like that. In order to get treated at the big hospital, big, wonderful hospital, I have to go through the emergency room.

Each time I go through the emergency room, I'm subjected to an environment which is filled with all sorts of germs which put me at risk. I'm there from between 6 and 36 hours. If anything goes wrong, [chuckles] I have to go through this limbo each time it happens. That's just the system. There's no other way around it. It's not the right way to operate, I got to tell you. I'm in there with people who are sicker than me, much sicker than me, not as sick as me. There are hundreds of people in the various bays of the emergency room, all of whom are in the same boat that I am.

Brian Lehrer: Sounds very frustrating. Did you ever ask anybody there the staff, why is it like that? Was it always like this? What can we do about this? I know it's not really up to them because it's structural, but have you?

Tom: Well, the emergency room staff, they are wonderful. That goes without saying, right? They're heroes. They just take what they're given. That's just their job. The people who are in charge of the program that I'm on just don't-- They say, "We don't have any choice. This is the only way we can admit you to the hospital."

Brian Lehrer: Tom? [crosstalk] Yes, go ahead. Sorry.

Tom: I was just going to say, I guess that comes from the hospital administration.

Brian Lehrer: Thank you for your call. I appreciate it. I'm sorry you're going through this, but again, it's good for people to hear that story at that level of detail. Dr. Rosenthal, you write in your Atlantic piece that hospitals today run like airlines and intentionally overbook. Gabor Kelen, if I'm saying that right, the director of Emergency Medicine at Johns Hopkins told you, "The problem isn't inefficiency, it's the way healthcare finance is structured." Is that new? Because I think part of your point is that when you were practicing in the ER, it wasn't always like this.

Dr. Elisabeth Rosenthal: Yes, well, remember, [chuckles] I converted to journalism in the early '90s, so it's been a long time. Yes, a bunch of things have changed. Hospitals have huge administrative staffs. They pay their CEOs a lot of money. They need to pay nurses more post-pandemic, which they probably should. Nurses have been underpaid for years. As I said, there were a couple of things. When I was in the ER doc, the hospital would cancel elective admissions if there weren't enough beds. They didn't run at full capacity.

They went on diversion, meaning we won't take any more ambulances because we're just filled to the gills until we can get some of these patients out of here, either discharged or up to a room. The big problem that the last caller refers to is physicians on the staff of hospitals used to do what were called direct admits. They would decide a patient need to be admitted and get them a bed assignment, and they would go to an admitting office and go up to the bed.

Now, hospitals have decided that every admit has to come through the emergency department. They get an ER evaluation. I don't know. You could argue that it's to make sure the ER docs are making sure that they really need to be in the hospital. There's also a financial motivation to do that. You get a lot of money for ER evaluations. I noticed on my husband's explanation of benefit statements, we were charged as if he were in a hospital bed each day he was boarding in the ER. They make money doing that. Then, eventually, they get up to a bed on the floor.

If you have a burst appendix or a hot appendix, you'll get that bed pretty quickly. If you're maybe an older diabetic person with a foot wound that needs antibiotics and dressing changes for a few days, you lie in the corridor, and boy, no one-- People like to talk to the doctors and say, "What can you do?" I think anyone who's watched The Pitt, one of the subplots that people like me notice is Dr. Robby following the administrator around saying, "Get some of these people upstairs, get them out of here. It's not good medicine. We can't take care of people, we can't take care of new patients."

The physicians, both your primary care physician or the person who's caring for your transplant, nor the ER doctors really have any power over this.

Brian Lehrer: Here's a text from a doctor who writes, "Thank you for bringing up this topic." He adds, he or she adds, "Sorry for your loss,' and writes, "I am a physician upstairs and worked for a major New York health system for 25 years. This problem has been going on for 20-plus years. One year, when the hospital I worked at had an average occupancy rate for the year of 103%, meaning more patient days than bed days, it had an operating margin of 2%. This was, I think, around 2010. Economics requires that hospitals are more than full to break even. Agree this is a terrible problem, but I don't know what the best next steps are. As things are, we can't afford the care offered. I'm all for single payer at this point," writes that doctor.

To finish up, the one concrete policy step that you report on in your Atlantic piece is a new rule that begins with voluntary reporting of boarding times in emergency rooms. That would start next year and become mandatory in 2028, with Medicare reimbursement penalties for bad-performing hospitals starting a couple of years after that. Tell us a little bit of how that would work, and do you agree with the doctor who wrote in that single payer would be full or partial cure?

Dr. Elisabeth Rosenthal: Well, first of all, I'm a journalist, so I can't say I agree that the solution to the US Healthcare problem is there are many, including single payer, and we are doing none of them. That's what I'd like to say. In terms of this new program that did go through at the end of the Biden administration, there was a report on emergency room boarding that suggested that a panel be convened to figure out solutions, which are not easy. The Trump administration came in, the DOGE program decimated that particular part of CMS, and the panel never happened.

They did implement a rule that you're talking about that, gosh, why wait two years for mandatory reporting and then this kind of nebulous Medicare penalties? I think the problem is there's so much money to be made, and I'm sorry to talk about this in financial terms, but this is how the bean counters see it, to be made by ER boarding. Even though it's horrible for patients, that how big a penalty can you-- My worry is the penalty will be like, "Okay, fine, we'll pay that." Also, enforcing hospital compliance in collecting these statistics.

Brian Lehrer: Just one quick follow-up, and we've got 30 seconds. When you say, and others say, "There's so much money to be made," at least in New York, the hospitals are nonprofit, so presumably they're trying to do whatever they can to work with those small margins that the former ER physician wrote or the upstairs physician wrote about, rather than trying to, "make money," because they don't have shareholders or owners. What would that question miss? 30 seconds.

Dr. Elisabeth Rosenthal: That question would miss that most nonprofit hospitals work like businesses. You go into the lobbies of these hospitals and the big marble lobbies, the good art, the pianos, they don't look like nonprofits, and they don't act like nonprofits. They define their profit as surplus, and they build more things, and they pay their executives more. There's a massive need to restructure how we think about what a hospital should be, too, so that, yes, they run on narrow margins, but they also spend money on a lot of stuff which isn't essential to health care, and that's all wrong.

Brian Lehrer: Dr. Elisabeth Rosenthal, author of the book that originally came out in 2017, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, now has her piece in The Atlantic called "A Barbaric Problem in American Hospitals is Only Getting Bigger," about boarding in emergency rooms. Thank you for sharing it with our listeners.

Dr. Elisabeth Rosenthal: Oh, thanks for having me. It's such an important topic.

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