After a financially disastrous year that ended with layoffs and an estimated $50.3 million loss from health care operations, the Cambridge Health Alliance expects improved results in the next 12 months but still anticipates losing money. And the end of Covid-19 aid and other special financial help has left CHA without a financial cushion that had protected it from bottom-line losses.

A proposed budget for the 2024 fiscal year, which began July 1, predicts that the Alliance will lose $19.1 million on operations and $7.1 million overall. The loss will come despite more revenue from patients and the layoff of 84 employees, according to the budget proposal. And officials weren’t happy about proposing a budget containing a loss.

“It is difficult to be understanding when you put together a budget that is in the red,” chief executive Assaad Sayah said. “We will do our best to not only meet these numbers but to better them.”

CHA is a safety net health care system serving a large number of low-income patients with government insurance such as Medicaid, as well as people with no health insurance. It operates two hospitals, in Cambridge and Everett, and clinics and care centers serving almost 130,000 patients in Cambridge, Somerville, Malden, Medford, Chelsea, Revere, Everett and Winthrop.

The system has struggled to maintain a consistent surplus and its predictions can be overly rosy, partly because it depends heavily on government aid. For example, CHA expected to earn $24.2 million overall in the fiscal year that just ended; instead, it was off by more than $57 million and now anticipates an overall loss of $33.4 million. The Alliance believed it would get $44.7 million in state and federal support for Covid-19 expenses and for new psychiatric units in Somerville and Cambridge; instead it got $4.6 million. The budget for this fiscal year doesn’t include revenue in this category.

Open meeting problem

Trustees on CHA’s finance committee discussed the fiscal year 2024 proposed budget at a June 27 meeting that was supposed to be open to the public. (Unlike other Massachusetts hospitals and health care systems, the Alliance is a public entity and must comply with the state open meetings law – with some exceptions). Instead, the public couldn’t attend most of the open portion of the meeting. Spokesperson David Cecere blamed Zoom glitches and other technical problems.

The glitches didn’t keep committee members and CHA managers out, but did prevent a Cambridge Day reporter from getting access despite registering in advance. Cecere, who was crucial in helping the reporter eventually join the meeting, said the committee didn’t know anyone from the public was registered and also wasn’t aware that anyone wanted to attend when switching abruptly from Zoom to Google Meet because Zoom had suddenly ended the meeting. Cambridge Day has filed an open meetings law complaint.

The meeting was not recorded, according to Cecere. The committee approved the proposed budget, which now goes to the full board of trustees for final action.

Psychiatric patients

While CHA laid off 84 employees and eliminated about 250 positions at the end of the 2023 fiscal year June 30, many of them vacant, it plans to increase staffing in the coming year and raise pay, according to the budget. The plan calls for adding the equivalent of 14 full-time doctor positions and 154 staff, the majority in psychiatry. In keeping with the increased staffing, the budget anticipates that more psychiatric patients will be admitted to a hospital bed in fiscal year 2024 and they will stay longer.

More people are also expected to visit its six-month-old Community Behavioral Health Center at Cambridge Hospital. The Alliance will open a second community center at its Malden Care Center in December, Cecere said. These facilities at sites throughout the state provide a range of psychological services, including walk-in urgent care. CHA opened the facility in Cambridge in January.

The budget predicts that visits to the CHA centers will almost double, to 9,984, in the coming year. There were almost 5,000 urgent care visits from January to the end of May this year, according to figures provided by Cecere. The majority were designated as “followup visits,” which Cecere described as “visits with patients we have recently seen for crisis evaluation and intervention. The purpose is to continue to provide brief crisis intervention and support to ensure that patients are recovering and connecting to the appropriate ongoing services to address their behavioral health issues.”

While the number of mental health urgent care visits are expected to increase, non-urgent behavioral health visits will remain about the same as this year, according to the budget. At the June 27 trustees meeting, Alliance leaders agreed with board of trustees chair Jim Lahey’s observation that CHA is “trying to shift away from the heavy emphasis on individual talk therapy.” Chief executive Sayah said the number of patients would increase but they will get fewer appointments. “The value is opening access,” he said.

More hospital stays

Those who need brief episodes of “more intense” treatment would get it, he said. In 2021, some mental health clinicians at CHA wrote to trustees saying they were alarmed at a move to a similar model of care, saying that many therapists and social workers had left because of the changes and that patients were enduring long waits for treatment. Cecere said the changes were “evidence-based,” provided more options to patients and that long-term care was still available. He also denied that many employees had left and that there were long waits for treatment.

The Alliance expects a sharp increase in the number of psychiatric patients who need to be admitted for a hospital stay, largely because of the significant expansion of beds for seriously ill children and adolescents at the Somerville site, according to the budget. Budget planners acknowledged that non-psychiatric inpatient volume has decreased in recent years, adding that “the opportunity to increase” those numbers “will be somewhat limited.”

Still, CHA will keep trying to admit more non-psychiatric patients by “increasing surgical cases requiring a hospital stay” and by developing “partnerships” that will allow the Alliance to take patients “from outside the CHA network,” the budget document said.

The Alliance also wants to discharge maternity patients sooner, making room for more to be served. CHA expects maternity volume to increase by a modest 1 percent, while patient days in the hospital drop by 12 percent, the budget said.

Maternity services

Another trustees’ committee, meeting on June 22, heard a report of “gaps” in maternity services at the Alliance, including a shortage of doulas, trained lay providers who support mothers before, during and after childbirth. There are seven doulas now, down from a high of 17, the trustees’ committee on population health was told at a meeting June 22.

The obstetrics/gynecological service no longer has a psychiatrist available to screen patients and no longer provides breastfeeding support after a mother leaves the hospital, the committee was told. There’s no coordination with mental health and social work services. “We really wanted to beef that up,” said Roberta Turri-Vise of the Alliance. “We focus so much on prenatal and birth when a lot of the struggles come post-partum.”

One committee member said MassHealth, which pays for care of low-income patients, doesn’t currently cover doula services. Another member said there is “an effort to have coverage this fall.” A MassHealth spokesperson was asked Monday about paying for doula services and had not responded by Wednesday.

CHA closed its birth center, a non-traditional childbirth option that operated in what looked like a private home across the street from Cambridge Hospital, during the pandemic. The Alliance may reopen the birth center in the 2025 fiscal year starting July 1, 2024, but only after renovating the building, updating policies and standards, adopting a new staffing model “to ensure safe, equitable care” and training employees – recommendations from a consultant hired by CHA to examine reopening the facility, Cecere said. Previously, officials have said patients can get all the services the birth center offered in the hospital-based maternity department.