Nurses ballot question raises patient care, medical cost concerns

When Massachusetts voters cast their ballots in November, they’ll be asked to decide on a long-running battle between hospitals and unionized nurses.

In short, should there be legal limits on the number of patients assigned to hospital nurses?

On one side are hospital administrators and a long list of medical organizations that say government-imposed ratios will drive up medical expenses, possibly by more than $1 billion, and take away the flexibility hospitals need to run their operations.

On the other is the Massachusetts Nurses Association and its allies in organized labor, community groups and politics who say that nurses are defending vulnerable patients from institutions more concerned about profits than people.

It’s a high-profile campaign filled with dueling studies, competing claims about the only other state with comparable legislation and pleas from nurses on both sides. As of early September, opposing groups had spent about $10 million on the question – about $7 million by hospitals and just under $3 million by the nurses’ proponents.

The state’s trade group for health insurers last week acknowledged the significance of the question, calling on the Massachusetts Health Policy Commission to help sort the claims by performing an independent analysis of possible impacts.

“Contradictory findings from proponents and opponents of this question make it hard for our organization to truly evaluate this proposal for its net impact on costs and quality improvement,” wrote Lora M. Pellegrini, president and chief executive of the Massachusetts Association of Health Plans.

Known as Question 1, the proposed law would establish specific limits on the number of hospital patients assigned to nurses. The limits would range from one to six patients per nurse, depending on the unit and severity of the patients’ conditions.

The limits would apply at all times. Hospitals could be fined $25,000 for each violation of the limits. If passed, the law would take effect Jan. 1, 2019.

Union nurses have been lobbying to enshrine nurse-to-patient ratios into Massachusetts law for 20 years, with little success.

State lawmakers passed legislation in 2014 that partly addressed the matter by setting ratios for intensive care units – typically one patient per nurse for the sickest patients, or two patients per nurse for those with less intense needs. But attempts to legislate broader measures have failed.

Unionized nurses also have tried to negotiate limits at the bargaining table. Nurses at St. Vincent Hospital in Worcester, which is owned by the for-profit hospital chain Tenet Healthcare Corp. of Dallas, have limits on patients written into their contract.

Still, said Marlena J. Pellegrino, co-chairwoman of the Massachusetts Nurses Association bargaining unit representing St. Vincent nurses, “having ratios in our contract is not enough. Tenet Corp. will try to get around our contract any way they can.”

A Tenet representative initially acknowledged a request for an interview on Question 1 but provided no further comment.

A significant body of academic research links higher hospital nurse staffing levels to better outcomes for patients. But the debate over Question 1 has thrown a flurry of competing studies and analyses before voters.

In a report compiled for the Massachusetts Health and Hospital Association, a trade group opposed to the measure, the research groups BW Research Partnership and Mass Insight projected passage could add $1.3 billion to hospital expenses in its first year and require the swift hiring of 5,911 nurses.

Meanwhile, a recent study of intensive care units in Massachusetts concluded that limits imposed on patient levels since 2014 actually had little impact on staffing and remained unassociated with changes in hospital mortality.

The only other state to legislate sweeping patient limits is California, which implemented its law in 2004. Studies there have looked at everything from waiting times at emergency rooms to hospital management practices.

A team of researchers from the University of California at San Francisco who examined a number of possible impacts at California hospitals reported in the journal Medical Care Research and Review in 2013 that growth in nurse staffing during the first few years was associated with just one improvement — lower rates of mortality after complication — although they said more time and study could determine other possible improvements.

Question 1 is going before voters at a time of transition for Massachusetts hospitals. State officials want to see growth in overall medical spending slow down. Insurers want hospitals to wring out expenses. Public insurance programs such as Medicare and Medicaid are also setting quality goals for hospitals – and in some cases cutting payments to those that don’t meet benchmarks.

Most Central Massachusetts hospitals reported modest profits in the six months ended March 31, according to the state Center for Health Information and Analysis. The most profitable hospital was St. Vincent with a surplus of $13.4 million. The biggest losses were $6.7 million recorded at UMass Memorial’s HealthAlliance-Clinton Hospital and a $4.1 million loss at UMass Memorial Medical Center.

Hospital executives say that against that backdrop, they would have to cut spending in other areas to meet the costs of recruiting, hiring, training and retaining the additional nurses needed to meet the limits. Lower-margin services such as behavioral health, they say, might go.

“This is a hospital that is mainly paid through Medicare and Medicaid, and the financial impact to us would undoubtedly be so significant we would have to close programs,” said Jessica Calcidise, vice president of nursing and ancillary operations at Harrington Hospital, which estimates it could face an additional $5 million in expenses if the question passes.

HealthAlliance-Clinton Hospital has been shuttering programs and slashing expenses already, but “those things which are very disruptive and upsetting to the community would pale in comparison to what we would have to do if this passes,” said Douglas Brown, chief administrative officer for UMass Memorial and president of its community hospitals.

UMass Memorial estimates passage of the law could add $36 million to $40 million to its expenses. Clinton campus could even close, Mr. Brown said.

“It’s hard to see how we’re going to be able to keep that campus open under the circumstances,” Mr. Brown said.

Some have also said patients could face longer waits to get into emergency rooms if hospitals do not have enough nurses available to treat them.

Heywood Healthcare hospitals can summon a “charge” nurse, or supervisor, from another unit to help in the emergency department when things get busy, but the hospitals do not have a bench of nurses they can quickly move into place if needed, said Dr. Ellen Ray, chief of emergency medical services at Athol and Heywood hospitals. Heywood estimates it could face an additional $7 million in expenses between the two hospitals.

“We basically flex up and flex down based on volume and acuity,” Dr. Ray said. “The problem with the ratios is it doesn’t allow for adjustments.”

But blaming nurses for those kinds of decisions rings hollow, according to Kate Norton, a spokeswoman for the Committee to Ensure Safe Patient Care, which is pushing for passage of the question. Hospital administrators are already closing unprofitable units, she said.

“Hospital executives make choices about where to put their money,” Ms. Norton said. “If hospitals in Massachusetts shifted just 3 percent of their operating budgets from executives to direct patient care, they would pay for more than half of what this bill proposes.”

Staffing plans filed by hospitals with the Massachusetts Health and Hospital Association, a trade group, suggest that some Central Massachusetts facilities may already be staffed at levels close to what the legislation proposes.

Take medical-surgical units, the places where patients who are acutely ill or recovering from surgery are likely to end up. The legislation seeks a limit of four patients per nurse on medical-surgical units. Central Massachusetts hospitals filings show that area medical-surgical units plan for staffing at levels ranging from about 3.5 to 4.5 patients per nurse, based on average numbers of patients per day.

But hospitals are complicated places. Patient levels can vary from hour to hour, day to day and season to season, especially in emergency departments. Hospital administrators claim they need flexibility, not government-mandated staffing ratios.

“It’s not a numbers game,” said Paulette Seymour-Route, interim chief nursing officer for UMass Memorial Medical Center in Worcester, a hospital with three campuses. “Professional practice and judgment comes into everything we do every day.”