As Vote Looms, Nurse Staffing Levels Debated at Hearing

October 18, 2018

By Colin A. Young


BOSTON -- With 20 days to go until Massachusetts voters will decide an initiative petition calling for nurse staffing requirements, health policy experts convened a panel Wednesday afternoon to try to understand what that proposed law’s impact on the cost, access to and quality of health care in Massachusetts would be.

The panel included a former head of the nurses union that has backed the ballot question, Boston Medical Center’s chief nursing officer, the chief operating officer of Blue Cross Blue Shield of Massachusetts, a researcher familiar with California’s nurse staffing laws and a regulatory policy specialist from California.

“One of the things commissioners want to understand is the difference between what happened in California and what potentially might happen here,” Health Policy Commission Vice Chair Wendy Everett said.

California in 1999 became the first state to pass a law requiring hospitals to meet minimum nurse-to-patient ratios. The law required the California Department of Health Services to establish specific ratios, while the ballot question here includes a set of ratios for various units and patient types.

“Two years after implementation, California’s staffing and patient care outcomes were compared to those in two other states using two expert-selected indicators. The comparisons revealed that California nurses cared for fewer patients than the other two states. The better staffing demonstrated significantly lower mortality,” Vicki Bermudez, a regulatory policy specialist from the California Nurses Association, said. “If the average ratios in both states had been equivalent to California’s, there would have been between 10 to 14 percent fewer surgical deaths for patients in those states.”

Dr. Joanne Spetz, a University of California-San Francisco professor brought on as a consultant to the HPC in August to study the nurse staffing proposal, said the study Bermudez referenced could not prove that the improvements in patient care were a result of the nurse staffing limits.

“It could not say that improvements in patient outcomes were strictly due to the regulations being implemented. That was correlational,” Spetz, who conducted the HPC’s own analysis of the ballot question, said. “The papers that have tried to use approaches that identify causal relationships have found no consistent patterns with the data that are available.”

The HPC’s analysis earlier this month pegged the cost of Question 1, which sets limits on the number of patients assigned to any one nurse, at between $676 million and $949 million, and said the state would need an additional 2,286 to 3,101 full-time equivalent nurses to comply with the proposed mandates. The estimated costs if Question 1 passes would represent 1.1 percent to 1.6 percent of total health expenditures, the commission found.

Dr. Judith Shindul-Rothschild, an associate professor at Boston College’s school of nursing and former president of the Massachusetts Nurses Association, the union leading the push behind Question 1, said it is “indisputable that better RN staffing levels lead to better patient outcomes and greater value, especially for high-risk patients.” She said that benefit was not properly taken into consideration in the HPC’s analysis.

Spetz said California implemented its nurse staffing ratios in the midst of a nationwide shortage of nurses. She said there was a spike in the number of traveling nurses who took work in California in the two to three years after the law went into effect there.

“I would anticipate that that would be a strategy that hospitals here would logically pursue,” she said.

Dr. Nancy Gaden, the chief nursing officer at Boston Medical Center, said there is already a shortage of about 1,200 nurses in Massachusetts, a job vacancy rate of about 5 percent across hospitals.

“I am alarmed at what would happen if Question 1 passed and what it would mean for the delivery of care at my hospital and at all hospitals across Massachusetts,” she said, adding that the proposed law would most seriously impact the emergency department and the labor and delivery department.

Gaden said the BMC emergency department would have to hire 52 additional full-time nurses to comply with the proposed ratios and that it would take a while for the hospital to be able to staff up. Until it did, Gaden said, up to 104 patients each day would be turned away from the BMC emergency room.

In the labor and delivery area, Gaden said, BMC would be forced to close one-third of all labor and delivery beds for expecting mothers until it could hire the about 20 new nurses the new law would require.

“That would mean that up to 800 mothers a year would be unable to come to Boston Medical Center to have their baby,” she said. “And I think they would have to go to Rhode Island or Connecticut or New Hampshire because every single other hospital in Massachusetts will have this same issue.”

Gaden and others said another concern with the proposed law is the effective date of Jan. 1, 2019. Everett, the HPC vice chair, said “we’re all a little anxious here about the miniscule timeframe we have to implement this.”

Gaden said BMC would not be able to hire the nurses it would need between when the issue is decided by voters on Nov. 6 and the Jan. 1 effective date.

“To be absolutely honest with you, if this passes, what I will focus on in November and December is closing areas” of the hospital, she said.