Current Events--Massachusetts Edition

Update 7/9/2018: Here's the text of the ballot question as certified by Massachusetts Attorney General Maura Healey. 

Just saw an ad on MSNBC opposing the Massachusetts Nurse-Patient Assignment Limits Initiative, a proposed question for the November ballot here in the Bay State that, if passed, “would establish patient assignment limits for registered nurses working in hospitals. Limits would be determined by the type of medical unit or patient a nurse is working with.” The measure is supported by the Massachusetts Nurses Association and the Committee to Ensure Safe Patient Care. (https://safepatientlimits.org)

As is typical when a referendum will hit an industry in the bottom line, the opposition group has a very similar name: it’s the Coalition to Protect Patient Safety, and it’s responsible for the ad I saw. (These fun facts courtesy of Ballotpedia: https://ballotpedia.org/Massachusetts_Nurse-Patient_Assignment_Limits_Initiative_(2018))

The Coalition’s ad campaign apparently launched May 22, although the ballot question still faces a court challenge and may require supporters to collect another 10,792 signatures by July 4. The ad uses the word “risky” a lot, and focuses on “rigid” staffing rules and the appealing notion that nurses know more about what patients need than “government” does. But the central claim is that the measure could cost hospitals in the Commonwealth a billion dollars a year. (You can see the group’s ads here: https://www.protectpatientsafety.com/video-testimonials/)

According to a study commissioned by the Massachusetts Health & Hospital Association, a hospital trade group that opposes the initiative, even that estimate may be too low: The report, from BW Research Partnership and Mass Insight Global Partnerships, claims the immediate cost may be $1.3 billion, with an ongoing price tag of $900 million per year thereafter. (Here’s the report: http://www.massinsight.com/wp-content/uploads/2014/04/MHA-NLR-Report-Final.pdf)

I know, that sounds like a lot of money, especially when it’s presented in the ad’s Dr. Evil intonation. I still get mixed up about how big a billion is, so I double-checked. A billion is a 1 followed by nine zeroes: 1,000,000,000. A thousand million. 

And here’s the thing: According to the Boston Business Journal’s most recent list of the state’s largest hospitals, which conveniently ranks them by net patient revenue, the top five hospitals alone collected $9.3 billion from patient charges in 2016. (If I do a lot more with this I’ll pay the $25 to BBJ to get the full 25-hospital ranking. https://www.bizjournals.com/boston/subscriber-only/2017/10/06/largest-hospitals-in-massachusetts.html)

Lest I mislead you with that word “net”, “net patient revenue” is the money the hospital collects for patient care once it subtracts things like unpaid patient bills, free/charitable care, and the discounts it gives to payers (such as private insurers, Medicare, and Medicaid, almost none of which pays the full hospital charge.) Net patient revenue may also include money paid to teaching hospitals for providing graduate medical education and government payments made to hospitals that serve a “disproportionate share” of low-income patients. But it’s not the “net” you may know from Accounting 101 as revenue-minus-expenses – subtracting expenses comes later in the hospital balance sheet. It’s just that healthcare is complicated (who knew?), so hospitals calculate this useful patient revenue number to differentiate it from gross patient charges. 

According to the Centers for Medicare & Medicaid Services, whose name officially includes the ampersand and which has, maddeningly, gone by the initialism “CMS” since 2001, payments to hospitals in Massachusetts in 2014 (the latest year available) were nearly $28 billion. (All the Excel spreadsheets you could want here: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsStateHealthAccountsProvider.html)

So what I’m saying is it’s possible that Massachusetts hospitals can afford a billion dollars to provide better nursing coverage. A billion dollars spread out across all the hospitals in the state is not as devastating an expense as it might be for you or me. It’s enough money to make a dent in their budgets, but it doesn’t have to bring the whole system crashing down around our ears.

Nonetheless, some parts of the BW/Mass Insight report read like a ransom note: If the ballot measure passes, “Hospitals report that they will either reduce services to reallocate resources to their core services or close certain units altogether. These reductions and closures will result in longer wait periods, fewer patient options, unequal care, and public health concerns.” 

The report continues: “The areas most affected by reduced services and unit closures include maternal health, seniors, substance use disorder, and behavioral health patients. In fact, community health benefits provided by hospitals would be among the most impacted element of the healthcare system; these are critical for low-income individuals, ethnic minorities, and immigrants.” 

In other words, opponents of the measure say services for the most vulnerable will be cut to pay for more nurses. The Coalition’s ad also warns that higher costs will be reflected in higher insurance premiums. 

The other issue raised by the BW/Mass Insight report is how hard it will be to find more nurses. Their research determined that hospitals would need to hire 5,911 more registered nurses to meet the requirements of the ballot question. According to the report, the pressure of finding nearly 6,000 more registered nurses will force hospitals to hire less-experienced RNs and pay them more – and potentially drive long-term care facilities and rural hospitals out of business when they can’t meet the required staffing ratios because they can’t offer nurses competitive salaries. 

But what does it mean if Massachusetts hospitals are currently 5,911 nurses short? 

According to The Massachusetts Health Professions Data Series: Registered Nurse 2014 Report (http://patientcarelink.org/wp-content/uploads/2016/08/HealthProfession-DataSeries-RN-2014.pdf), in 2014, there were 123,862 registered nurses with active Massachusetts licenses. The estimated 5,911 is about 4.8% of that number.

(In a meaningless coincidence, 4.8% of the licensed nurses are unemployed, mostly because they’re caring for family members. I’m not suggesting that means the unemployed nurses should abandon their loved ones. But it does lend some perspective to the shortfall.)

If Massachusetts hospitals are only about 5% short of ideal nursing staff levels, it probably does imply that patient safety is not seriously affected in most hospitals at present.

But there are disparities – hospitals where the nurse-to-patient ratio is worse than average – and those are the institutions that will be hit the hardest if the ballot question passes. Where proponents see the measure as bringing all hospitals up to a standard level of nursing staff, opponents emphasize that smaller and more rural hospitals will feel the brunt of the change, and are least able to afford it.

As the BW/MassInsight report put it: “Communities outside of Boston and Worcester, such as the Cape and Islands, MetroWest, and Western Massachusetts are all at risk of losing entire facilities.” Already, these areas are becoming the battlegrounds for the initiative, with the Massachusetts Health and Hospitals Association telling the Boston Globe that “Cape Cod Hospital would have to spend more than $24 million to comply with the ballot question, MetroWest Medical Center would have to spend $15 million, and South Shore Hospital $33 million.” (https://www.bostonglobe.com/business/2018/04/29/proposal-set-patient-limits-for-nurses-would-cost-hospitals-year-industry-backed-study-says/2JAoCKn5gxx0opeqcE6Q8L/story.html)

The other important issue for both sides is what will happen in the future. If staffing levels are set by law, any future reductions will also require a legislative effort. Proponents want to lock in the current level of coverage -- which would protect both patients and jobs. Opponents want the future freedom to make cuts technology and other factors may make possible – or that fiscal concerns may demand. 

The Massachusetts Nurses Association points to its annual survey, which shows a dramatic increase in the percentage of nurses reporting problems due to understaffing: “64% of RNs report injury and harm to patients due to understaffing – up from 46% in 2014.” (https://safepatientlimits.org/what-we-stand-for/according-to-nurses/)

While the survey charts nurses’ opinions rather than documented incidents, that’s still a telling increase in professional concern. For these nurses, understaffing is a problem, and they don’t want to see it get any worse. 

Patient-to-nurse ratios do have an effect on patient safety and quality of care, but optimal levels have not been definitively established. Are the staffing levels in the initiative the ideal ones? We probably won’t have that confirmed before November. 

Posted 6/1/2018

Updated 7/9/2018 with link to the initiative as it will appear.