October 15, 2018

Labor vs. Administration: Ballot pits nurses against hospitals

Becker College Professor Enoh Ukpong trains nursing students. If Question 1 passes, the demand for nurses will increase.

Labor-versus-management fights usually take place in a meeting room, or maybe on the picket lines. This one will take place at the polls.

Massachusetts voters will go to the ballot Nov. 6 to decide whether limits should be placed on how many patients are assigned to a registered nurse at a hospital or other care facility.

Question 1 has sharply divided the nursing community, with a major union, the Massachusetts Nurses Association, in favor of the proposal. Other industry groups – including the Massachusetts Health & Hospital Association and the American Nurses Association of Massachusetts – are against the proposal, as are the administrations at many of the hospitals they represent.

For at least some nurses, the ballot question is a chance to make up for staffing shortages they say have left too few nurses caring for too many patients. Lyn Flagg, an emergency department nurse at UMass Memorial Medical Center in Worcester, said she's seen patient workloads get worse in the past five years.

"My assignments can be horrifically unsafe," said the Shrewsbury resident and a nurse for over 25 years. "It's impossible to keep up with appropriate care."

For hospital administrations, the mandated ratios would bring what they say are heavy costs.

Milford Regional Medical Center predicted a devastating impact if the patient-to-nurse ratio is approved. Higher costs associated with higher staffing levels could hit nearly $5 million, the hospital said, which would result in bed closures, reduced patient services and delayed upgrades in technologies.

"The unintended consequences of this ballot question would reverse all of the progress we have made in patient care in the last decade," said Judy Kelly, Milford vice president of patient care services.

Heywood Hospital in Gardner said it would face $1 million in additional costs in its emergency department alone, while Worcester's Saint Vincent Hospital said it would face $18 million in new costs annually. Saint Vincent said it's also worried about other costs.

"Question 1 would be devastating for local community health centers, local nursing homes, behavioral health treatment, and home care," spokeswoman Daisy Burroughs said. "These are crucial components of our healthcare system, and our most vulnerable community members should not be left without the care they deserve."

UMass Memorial Health Care has estimated its additional costs would hit $36 million to $40 million annually, all but ensuring personnel and programs would have to be cut elsewhere.

Finding & paying more nurses

The staffing threshold would elevate nursing staffing above all other caregivers, which is not in the best interest of the organization or patient care, Eric Dickson, the president and CEO of UMass Memorial Health Care, wrote in a blog post last month.

Douglas Brown, UMass' chief administrative officer, said a passing of Question 1 could require UMass to cut unprofitable programs benefiting lower-income patients or close money-losing HealthAlliance-Clinton Hospital.

"This is the biggest threat to health care, and certainly to our system, in well over a decade," Brown said. "It would truly be devastating."

At Worcester's UMass Memorial Hospital, close to 300 nurses are projected to be needed to meet the new standards. Brown said hiring that many nurses, when positions are already unfilled, would be hard, especially if salaries rise to match the flood of new positions.

"The problem is, these nurses aren't available," Brown said.

Proponents of the ballot question, on the other hand, say cost estimates are exaggerated. One study cited by the Committee to Ensure Safe Patient Care, which is campaigning for the new staffing standards, pegged additional hospital costs at less than $47 million across the state, a fraction of what opponents have said.

Flagg doubted hospitals couldn't absorb the costs, and nurses weren't allowed to take part in the hospital's cost analysis, even after they asked.

Flagg wasn't sure what to predict for Nov. 6.

"The hospitals are fearing it'll pass, and I'm fearing it's not going to pass," she said.]

Proponents include U.S. senators Edward Markey and Elizabeth Warren and U.S. Rep. Jim McGovern of Worcester.

HPC: High cost, little benefit

The state's Health Policy Commission released a nonpartisan report on the issue Oct. 3, estimating costs for hospitals and other facilities would rise by up to $949 million a year.

The commission said new standards would force hospitals to increase staffing by 2,286 to 3,101 additional full-time equivalent registered nurses. Community hospitals serving higher proportions of MassHealth and Medicare patients would be affected the most.

Savings would be realized through reduced hospital stays, the commission said. But those possible savings, roughly $34 million to $47 million, would be far more than offset by higher costs. An estimated $676 million to $949 million in additional annual costs are likely conservative, the commission said, because of a lack of detailed staffing data for some units, including emergency and outpatient departments.

Only California has mandated staffing ratios like what is proposed for Massachusetts. Implementation in California was done in stages over several years, the Health Policy Commission said, while in Massachusetts, they would go into effect quickly, by the start of 2019. California standards are less strict.

The commission said no systematic improvement in patient care was found in California after the standards went into effect.

Public opinion seems to have shifted after the state's report.

A UMass Lowell poll released Oct. 10 found 51 percent of likely voters oppose the mandate, and 43 percent support. That's compared to a September poll finding 52 percent in support.

Another poll, by WBUR in September, found 44 percent both for and against the staffing question.

More staff, narrow margins

The financial question is an important one for hospitals always fighting rising costs.

MetroWest Medical Center, Nashoba Valley Medical Center in Ayer and HealthAlliance-Clinton Hospital each ran financial losses in the 2017 budget year, while Emerson Hospital in Concord and UMass Memorial Medical Center in Worcester both had profit margins of under 2 percent.

Four Central Massachusetts hospitals had profit margins of 6 percent or more: Athol Memorial Hospital, Harrington Memorial Hospital in Southbridge, Marlborough Hospital and Saint Vincent Hospital in Worcester.

If the question passes, standards would vary by specialty. In the emergency department, a nurse would be in charge of just one critical patient at a time, or two patients if the nurse has assessed each patient's condition as stable. A nurse could have up to five patients if they are deemed non-urgent stable.

So far, financial support has largely gone to those looking to strike down the ballot question, according to the Massachusetts Office of Campaign & Political Finance.

The Coalition to Protect Patient Safety, which was organized with an aim of defeating the staffing requirement, reported roughly $10.5 million in donations through mid-September, along with $9.2 million in spending, largely on advertising, consulting and polling.

Nearly all of the donations have come from the advocacy group Massachusetts Health & Hospital Association, which claims 70 member hospitals.

The Committee to Ensure Safe Patient Care has received $5.7 million in donations in support of Question 1. Nearly all came from the Massachusetts Nurses Association, with 23,000 members at 85 healthcare facilities.


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