“These measures are designed to capture failures in emergency care access,” Dr. Michael said. “From CMS’s perspective, that’s a hospital system issue—not just an ED metric.”

Why Incentives Matter

Although measurement is important, many experts believe financial incentives will ultimately determine whether hospitals make sustained changes.

Dr. Abir

According to Mahshid Abir, MD, MSc, a RAND researcher who helped lead the analysis, interviews conducted for the study revealed strong consensus among emergency physicians and policy experts.

“The majority of emergency physicians and emergency care policy experts interviewed believe that the most effective solution to ED boarding is tying it to payment,” Dr. Abir said.

Without financial incentives or penalties tied to boarding performance, health systems may struggle to prioritize long-term operational changes. Experts interviewed for the RAND study also emphasized the need for standardized national metrics.

“Federally mandated metrics are needed to track ED boarding at hospitals and measure the effectiveness of implemented solutions,” Dr. Abir said.

Such transparency could help policymakers, hospital leaders, and clinicians better understand how boarding varies across hospitals and whether new strategies are working.

Structural Bottlenecks Beyond the Hospital

Even when hospitals try to improve patient flow, broader system constraints often interfere.

Patients who are medically ready for discharge may remain hospitalized because appropriate post-acute placements are unavailable. Skilled nursing facilities, rehabilitation centers, and behavioral health beds remain limited in many parts of the country.

Insurance authorization requirements and administrative processes can also delay transfers. “These outflow bottlenecks create major challenges,” Dr. Michael said. “Patients who are medically ready for discharge can remain in hospital beds for days.”

When inpatient beds are occupied, patients admitted through the emergency department cannot be moved to an upstairs bed. The result is boarding.

The RAND report also highlights national trends contributing to the problem, including declining inpatient bed capacity relative to demand and geographic mismatches between hospital resources and patient needs.

Where Solutions Must Start

If the emergency department is not the cause of boarding, where should solutions begin? Dr. Kelen’s answer is direct. “The emergency department doesn’t cause boarding,” he said. “Boarding is a hospital problem.”

Addressing it requires engagement from hospital leadership, particularly the executive suite. “When hospital leadership—especially boards of trustees—tie executive compensation to boarding metrics, change happens fast,” Dr. Kelen said.

At Johns Hopkins, he noted, leadership tied executive compensation to boarding metrics. “Within weeks,” he said, “boarding was dramatically reduced.” Accountability, he argues, is critical. “When everyone has skin in the game, the system responds.”