The ripple effects of Question 1: Perspectives from across health care

  • Cooley Dickinson Hospital. STAFF PHOTO/CAROL LOLLIS

Staff Writer
Published: 10/27/2018 12:33:00 AM

NORTHAMPTON — Voters will be faced with several ballot questions when they head to the polls on Nov. 6, but none has been been more hotly debated than Question 1.

The measure, if passed, would limit the number of patients that a hospital nurse could be assigned. The question was written by the Massachusetts Nurses Association labor union, or MNA, which has been the driving force behind the “yes” campaign. The Massachusetts Health & Hospital Association, which lobbies on behalf of hospitals, has spearheaded the “no” campaign.

Much of the media focus on Question 1 has centered on the perspectives of hospital nurses, doctors and executives. But the initiative will have implications across other parts of the health care system, and it is drawing opinions from all corners of the health care field and beyond.

“It’s a very important one because there is so much money and so much skin in the game on so many people’s parts,” said David Chin, an assistant professor of health policy and promotion at the University of Massachusetts Amherst.

Both supporters and opponents of the measure seem to have chosen “patient safety” as their primary talking point for the public. The “yes” campaign, for example, is called the “Committee to Ensure Safe Patient Care,” and the “no” campaign goes by the “Coalition to Protect Patient Safety.”

Chin said the question of nurse-to-patient ratios has been a continually recurring one among public health researchers like himself who measure hospital quality.

“Everybody in my whole career has been committed to making hospitals safer,” he said. “I don’t believe this is a vehicle to achieve that goal … I don’t think there’s evidence that it improves quality and it improves safety.”

The MNA and the campaign to pass Question 1 have disputed assertions that putting limits on patient-to-nurse ratios wouldn’t improve quality and safety. They have pointed to studies that show that when nurses care for too many patients at once, those patients are at increased risk for complications, such as infections.

But when trying to achieve the maximum possible benefit for safety in relation to the amount of money spent, Chin said the proposed ratios would not be the best allocation of those resources. He said the nurse-to-patient limits as written in the ballot initiative are “incredibly restrictive” for staffing managers, and would have to be implemented almost immediately if the question were to pass. 

However, questions of hospital quality and safety should be separated from the issues of nurse burnout and patient satisfaction, Chin said. 

“Nursing burnout is a very, very huge problem in the health care delivery system as a whole,” Chin said.

Chin said he wishes the state would study the question and develop an empirical estimate of what nurse-to-patient ratios should look like. “In the perfect world, study it before it becomes put forth to the electorate.”

The MNA has for around 20 years tried to get lawmakers on Beacon Hill to systematically address nurse-to-patient ratios. Finding little success on that front, the union has now successfully put the question before voters as a ballot question.

Although the question has drawn discussion around the issue of patient safety, it also has implications for organized labor. Nurse-to-patient ratios have been a frequent point of contention between hospital management and nurses’ unions, including in a recent strike at Baystate Franklin Medical Center in Greenfield. The success of the ballot question will have lasting impacts on negotiations between nurses and management.

Michelle Reardon, a unionized recovery specialist at Providence Behavioral Health Hospital in Holyoke, said that solidarity with the nurses’ union is part of the reason she is voting “yes” on Question 1. 

“I feel like we have to support the MNA, who are the people doing the work,” she said. 

Reardon is a member of the United Auto Workers Local 2322, and co-chairs the bargaining unit at Providence that represents mental health counselors and methadone treatment clinicians. She said nurse-to-patient limits would benefit both nurses and those who work next to them.

“Everybody’s overworked for what they expect us to be able to do,” Reardon said. With nurse-to-patient limits, “it’s obvious that it would take work away from everybody, and it would obviously provide better care for the patients.”

A recent Mass Inc. and WBUR survey found that 41 percent of nurses said they were “very frequently” or “somewhat frequently” given a larger patient load than they could handle.

A concern raised by some opponents of Question 1 is that wait times for emergency departments will increase — an issue that the state’s Health Policy Commission also raised in its analysis of the ballot question.

That has led some opponents of the measure to raise questions about whether emergency medical service, or EMS, professionals would choose to go to a different hospital to avoid waiting in line.

“This ‘hospital shopping’ can lengthen the time it takes for a patient to get into an emergency department as well as take EMS professionals out of service longer,” Cooley Dickinson Hospital emergency department nurse manager Sara McKeown said in a statement to the Gazette.

But Amherst Fire Chief Tim Nelson, whose department runs the town’s ambulance services, said that argument is inaccurate.

“We are by law supposed to take a patient to the closest appropriate medical facility. We’re not going to shop,” Nelson said. “We have to do what’s right and take them to the appropriate facility ... We are bound by law, by ethics and by just taking good care of the patient.”

Emergency departments are prevented from turning away patients under federal law, and Massachusetts is a “non-diversion” state, meaning that emergency departments are legally barred from turning away patients if they are overcrowded.

Currently, emergency room wait times in Massachusetts are some of the longest in the country, according to hospital data gathered by ProPublica, which found that the state ranked 48th out of the 50 states in average wait times.

Nelson declined to say how he is voting on Question 1. He did say he has concerns about how quickly hospitals will have to implement the nurse-to-patients limits. The question’s language says they will come into effect on Jan. 1, 2019, if passed, but the head of the state's Health Policy Commission has said that language doesn't include any timelines for regulatory action.

Some in the community health services field have worried about the ripple effects the ballot question might have on their institutions.

Sue Stubbs, the president and CEO of the Northampton-based human services agency ServiceNet, said she is concerned that the question will make it more difficult for her organization to hire nurses. 

“We have psychiatric nurses that work in both clinics, and now we can’t afford to pay what hospitals pay,” Stubbs said. “We often lose our nurses, who often leave to work at a hospital and make more money.” 

Stubbs said that, given the $25,000 maximum fines — per violation, per day — that hospitals could face if they didn’t comply with the Question 1 patient limits, she imagines those hospitals would bump up wages to attract nurses.

Steve Wilson, 62 of Montague, is a counselor with ServiceNet. He said that he has seen nurses at the residence home where he works overburdened with work; one nurse, he said, left for a local hospital. Even though he doesn’t work in a hospital, Wilson said he has seen how the lack of nurse-to-patient limits can lead to difficult situations for both nurses and staff.

“The more patients a nurse has to see, the less time they have to see that patient. Which means more of those nursing duties would fall on the staff,” he said. “A lot of the stuff she would have done, it fell to us to do.”

Should the measure pass, Stubbs said, she worries that behavioral health units in community hospitals would have to close, given the already low reimbursement rates from Medicaid and the high cost of hiring more nurses.

Indeed, Trinity Health of New England, which operates Providence Behavioral Health Hospital, has said that they already lose $12 million per year at Providence. If Question 1 passes, they’ve said it might force them to close Providence.

But Reardon, the Providence recovery specialist, said she thinks Question 1 will simply be the excuse Trinity Health — which pulls in $1.6 billion in annual revenue, according to their website — will use to make cuts they already planned to make. Trinity already laid off Providence staffers this summer, citing rising costs and inadequate reimbursements from insurers and the government for mental health care, according to reporting from The Republican.

A WBUR poll late last month found the “yes” and “no” campaigns in a dead heat on Question 1, though a UMass Lowell and Boston Globe survey from earlier this month found 51 percent of likely voters oppose the measure  and 43 percent support it.

This story has been updated to reflect the fact that $25,000 is the maximum fine a hospital can face, and that the measure’s language doesn't include any timelines for regulatory action.

Dusty Christensen can be reached at dchristensen@gazettenet.com.


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