Overview: a system under extreme strain

The Massachusetts Health & Hospital Association (MHA) describes a statewide hospital system in crisis: tens of thousands of positions unfilled, longer waits for care, and costs escalating at a pace hospitals cannot sustain. The workforce shortage interacts with capacity constraints and thin (often negative) margins to produce delays across the continuum of care—from emergency departments (EDs) to inpatient floors to post-acute settings. The report’s purpose is to quantify these pressures and connect the dots between staffing gaps, care bottlenecks, and worsening financial performance, while outlining steps the Commonwealth can take to stabilize access to care.

The workforce shortage, by the numbers

A 2022 MHA survey of acute-care hospitals (covering ~70% of the state’s acute-care employment) counted 6,650 vacancies across 47 critical roles—from bedside nurses and respiratory therapists to laboratory personnel and unit support staff—with a median vacancy rate of 17.2%. Extrapolating across all positions suggests roughly 19,000 hospital jobs are unfilled statewide. Vacancy rates exceed 20% in 18 of the 47 roles, and are particularly acute in categories such as Licensed Practical Nurse (56%), Pulmonary Function Technician (35%), Home Health Aide (34%), and Mental Health Worker/Technician (32%).

Crucially, these hospital-side shortages sit inside a broader, system-wide shortfall: post-acute and community services (skilled nursing facilities, home health, behavioral health programs) are also short-staffed. As a result, hospitals struggle to discharge patients who are medically ready to move on, which backs up EDs and inpatient floors. Add seasonal pressures (flu), potential COVID resurgences, an aging population, and worsening behavioral health needs, and hospitals are pushed toward surge operations with limited reserve.

Skyrocketing labor costs and the “traveler” bill

Labor is the dominant expense in hospital operations—typically ~70% of each operating dollar when you add wages, benefits, and purchased services. In the current market, those labor costs have spiked: median average hourly wages for the 47 surveyed positions rose by more than 13% vs. pre-pandemic levels, with many roles seeing 20%+ increases. This includes signing bonuses, retention incentives, and other measures to keep bedside teams intact.

Because vacancies persist even after substantial compensation increases, hospitals have relied heavily on high-cost temporary staffing agencies. The average hourly rate for travel RNs has risen ~90% since 2019. Spending on temporary RNs in Massachusetts jumped 234% from FY2019 to March 2022; by mid-FY2022, hospitals had already spent $445 million on temp RNs—more than full-year totals in prior years—and the state was on pace to approach $1 billion on temporary RNs by year-end. Temporary non-RN clinical staffing added roughly another $350 million annualized. These costs, in a high-wage state to begin with, are labeled “simply unsustainable” by hospital leaders.

Financial losses and thin (often negative) margins

Even as they stayed open throughout the public health emergency, many hospitals moved into the red. As of June 30, 2022, the statewide median operating margin was –1.4% and the total margin –4.4%—both materially worse than the prior year. 78% of 59 reporting hospitals had negative total margins, and 39 of 41 hospital-affiliated physician organizations reported net losses. Aggregate expenses exceeded aggregate operating revenue by $278 million through June 2022, despite government relief, and providers reported more than $2.5 billion in additional pandemic-related losses. Inflation compounds the problem (labor, fuel, supplies, drugs, cybersecurity) and, unlike other sectors, hospitals cannot readily pass increased costs to patients. The upshot: hospitals face difficult choices, including potential service reductions, if conditions persist.

Capacity constraints: when workforce meets rising acuity

Staffing gaps collide with higher and more complex patient volumes to create severe capacity constraints. The report cites increases in ED demand, inpatient and ICU admissions, and the number of staff out on leave or affected by COVID. Patients who delayed care during earlier pandemic phases often arrive sicker and require longer stays, which stretches teams further and slows patient flow. These delays also spill into the outpatient arena—procedures and visits can back up when inpatient services and diagnostics are saturated.

Surge capacity pressures

Regional Health and Medical Coordinating Coalitions (HMCCs) have continued meeting to share capacity and clinical data. Several regions report movement toward “surge capacity,” meaning operational volume that challenges or exceeds normal staffing and space. The report anticipated additional strain through the 2022–2023 winter due to flu admissions and possible COVID resurgence, all on top of the existing workforce deficit.

Behavioral health: reduced staffed beds and ED boarding

Behavioral health is a critical pressure point. Nearly 20% of inpatient psychiatric beds in Massachusetts hospitals are offline because there are not enough workers to staff them. Meanwhile, EDs continuously care for patients who are awaiting psychiatric evaluation or an inpatient behavioral health bed. Over the prior year, about one quarter of staffed ED beds statewide were occupied by behavioral health boarders on a typical day; at times, individual hospitals reported 100% of ED beds filled by boarders. This phenomenon increases waits for all other ED patients and reverberates into inpatient units. Even after stabilization, patients can wait weeks or months for appropriate community-based or continuing-care placements because of downstream shortages.

Post-acute bottlenecks: “ready but waiting”

Discharging medically ready patients is increasingly difficult when post-acute settings are short-staffed or full. On a typical day, close to 1,000 patients in Massachusetts hospitals are waiting for post-acute placements (e.g., skilled nursing facilities, LTACHs/IRFs, home health). Massachusetts nursing facilities report ~23% vacancy rates, so beds that exist on paper may not be operational in practice. The duration of delay is striking: in August 2022, over 40% of patients awaiting discharge to certain post-acute settings had been waiting more than 30 days, and such prolonged waits were a sustained pattern across the months analyzed. These “stuck” patients tie up beds and staff, slow ED throughput, and dampen access for new patients.

Human impact: longer waits and rising violence

From a patient and family perspective, the crisis shows up as longer waits, fewer available services, and care delivered in suboptimal locations (for example, extended ED boarding). The report notes a marked rise in violence and incivility directed at healthcare workers, a phenomenon linked both to heightened frustration and chronic stress. On the caregiver side, burnout and moral distress are widespread, further fueling attrition and vacancies—a vicious cycle that worsens capacity and safety risks. The classic aim of delivering “the right care, at the right time, in the right place” is threatened by intertwined workforce, capacity, and financial shocks.

A call to action: five policy levers

MHA’s recommendations focus on immediate stabilizers and longer-term pipeline development:

Advance new models of care. Maintain pandemic-era flexibilities that allowed licensure and staffing agility; scale telehealth and Hospital-at-Home models that extend clinician reach and bring care to patients more efficiently.
Expand the workforce pipeline. Launch a statewide campaign to attract people into healthcare careers with direct “learn-and-earn” pathways; prioritize RN recruitment and development across the continuum.
Invest in training and advancement. Increase training in behavioral health, substance use, and trauma-responsive care across settings to safely discharge patients to non-hospital environments. Extend loan forgiveness, scholarships, and pipeline investments beyond behavioral health to the full healthcare workforce. Consider an “AmeriCorps-type” program that pairs targeted tuition assistance with service commitments.
Protect healthcare workers. Enact robust workplace-violence prevention measures, including enhanced penalties for intentional violence against healthcare personnel; promote zero-tolerance policies and cultivate a strong reporting culture.
Provide financial support and reform. Seek additional federal relief and deploy remaining ARPA funds; incorporate today’s extraordinary pressures into cost-growth benchmark discussions and policy reforms so providers are not penalized for factors outside their control and have room to stabilize operations.

Bottom line

The report’s overarching message is sobering: Massachusetts’ hospital system has never been more fragile. High and rising costs, extensive vacancies, downstream bottlenecks, and escalating patient needs are converging to threaten timely access to care. Without coordinated action by providers, payers, policymakers, and agencies, waits will lengthen and services will become harder to access. With targeted relief, modernized care models, and a rebuilt pipeline—from entry-level aides through advanced practice clinicians—the Commonwealth can begin to restore flow, protect workers, and keep care accessible to the seven million residents who depend on it.

Disclaimer

This summary is for general informational and educational purposes only and does not constitute medical, legal, financial, or policy advice. Operational conditions, costs, and regulations may have changed since the report’s publication (October 2022). Patients should consult their own clinicians for medical guidance; organizations should consult legal and policy experts before making operational decisions.

Source

Massachusetts Health & Hospital Association (MHA). An Acute Crisis: How Workforce Shortages Are Affecting Access & Costs. October 2022. (PDF).

Healthcare News & Policy

Massachusetts Hospitals in an Acute Workforce Crisis: Access, Capacity, and Cost (MHA 2022)