Question One: Nurse Staffing Ratios – “a riddle, wrapped in a mystery, inside an enigma.”

October 3, 2018

By: Joe Alviani, Senior Advisor of Strategy & Policy

The confusion and conflicting claims attendant the opposing arguments on Question One, the mandatory nurse staffing initiative on this November’s state ballot, embodies the sentiment of the Churchill quote above in describing Russia after World War II.

Whether it’s the dueling economic cost studies offered by the parties or the surveys suggesting that nurses in large numbers support or oppose mandatory staffing ratios, the electorate (and the media) seem confused by the politics and the policy of this complex issue.

Let’s try to navigate these conflicting positions in an effort to provide some clarity because the stakes are high.

First, costs: The parties appear to disagree on the amount of added costs to hospitals of implementing mandated nurse staffing ratios, not that there will be in fact substantial incremental costs. The differences in the estimates of cost are not minimal. The variance between the billion dollar price tag suggested by the Massachusetts Hospital Associate (MHA) and Mass Insight studies and the nearly $50 million proposed by the Massachusetts Nurses Association (MNA), the union sponsoring the ballot initiative, is significant. But, there should be no argument that hospitals will bear an increasing burden, thus raising the overall costs of health care in the Commonwealth (the impact of the ballot initiative on health care costs is deemed significant enough that the state’s Health Policy Commission, charged with controlling health care costs, is now conducting its own study of the issue). It is not unfair then to ask who will ultimately bear those increased costs – hospitals, insurers in necessarily higher reimbursement payments or consumers in higher premiums. There should also be little argument that the impact of these added costs will be felt more by community hospitals, many of which already suffer with small or negative margins, and a few of which claim they may be threatened with closure if the measure passes. The requirement for increased staffing to meet the patient to nurse ratios will require many of these community hospitals to hire more nurses, clearly something that larger hospitals and hospital systems are in a better – if not enviable – position to absorb. The MNA argues that hospitals can afford the increased costs since they are already paying executives high levels of compensation and spending on new buildings and facilities. However, medicine is changing, new technologies and treatments are advancing at rapid and costly rates, and new facilities are necessary to improve the patient experience and make operations more efficient.

Second, staffing flexibility: The union argues that mandatory ratios will improve patient care because there will be a manageable ratio of patients to nurses thereby enabling the proper amount of individual attention to individual patients. The opponents of the ballot initiative counter that imposing hard and fast ratios limits the nimbleness necessary in real world hospital operations. In particular, the hospitals point to the impact mandatory ratios would have in emergency situations when the ability to move nurses from one service to another is critical to respond to unexpected events and catastrophes, e.g. fires, bombings, etc. Nurse administrators contend that mandatory ratios tie their hands not only in emergency situations, but also in normal day to day occurrences. Some nurses opposed to the ballot initiative express concern that the ratio requirement will affect their own flexibility and work schedules since they may be compelled to stay in a ward or on a floor in order to comply with the mandatory staffing rules.

For psychiatric hospitals and other behavioral health facilities, the cost impact and limits on flexibility are compounded since many of them provide patient care through non-nurse personnel like social workers and psychologists. If compelled to provide licensed registered nurses for its patients pursuant to mandatory nurse staffing ratios, the expense would rise dramatically and even their viability, since they currently receive inadequate reimbursements, could be called into question.

Third, support of nurses: Let’s be clear that all of us value and respect the incredible work that nurses do day in and day out. They are truly the caregivers of first resort for patients. But, the MNA does not represent all nurses. In fact, the union represents a little less than 25 percent of the Massachusetts nurses. There are then differences of opinion on the ballot initiative among nurses – whether union or not – best exemplified by the warring TV ads with nurses advocating on both sides of the question. The ballot initiative is sponsored by the MNA, but not by all nurses. So, when you hear polls or surveys of nurses on either side of the initiative, it’s important to understand the differences of opinion and always question the validity of those numbers.

Many policy makers and elected officials – current and past – and I am one – contend that complicated and multi-faceted issues like health care should not be resolved by ballot initiatives, but rather by a deliberative process that enables consideration of unintended consequences. Further, in cases like hospital operations where the unexpected and emergency situations are the norm and not the exception, it seems shortsighted. – not only as a policy – but practically in meeting patient needs – for the hands of the hospital leadership and nurse administrators to be tied in responding to staffing demands of the moment.

The confusion generated by Question One underscores the imprudence of addressing complex issues through the ballot. Nurse staffing ratios has proven itself to be one of these complex issues.

NOTE: Additional cost information was released this morning. 

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