Nurse staffing study left union in the dark
Nurses’ association faults state panel on pivotal report
THE CONTENTIOUS BALLOT QUESTION campaign over nurse staffing levels may be over, but bitter feelings remain over a study that played a pivotal role in the high-profile debate.
In early October, the state Health Policy Commission released an analysis estimating the potential impacts of Question 1, which would have mandated minimum nurse staffing levels in Massachusetts hospitals. The report projected the ballot question would, if approved, add up to $1 billion a year to state health care costs without any clear evidence that it would enhance patient safety and care.
The report was clearly within the purview of the commission, which was established in 2012 with the goal of monitoring and reining in Massachusetts health care costs. The commission regularly analyzes proposed hospital mergers and other factors contributing to rising health care costs, and in most cases the parties involved know an analysis is coming. What made this report so unusual was that it was done in tight secrecy, and it was dropped like a bombshell into the political debate with only one side knowing it was coming.
The Massachusetts Nurses Association, which brought the question to the ballot, says it was “blindsided” by the report, which the union was never told was in the works. Meanwhile, the Massachusetts Health and Hospital Association, the main backer of the campaign to defeat the ballot question, knew about the report because it provided data that was used in the commission’s analysis.
The report became a crucial part of the ballot question debate, with news stories following its release regularly citing it as the only independent analysis of the nurse staffing measure. The cost estimate in the state analysis closely paralleled the projection in an earlier report issued by the hospital association.
The ballot question was soundly rejected, losing by a 70-30 margin.
“It had an enormous impact,” Schildmeier said of the Health Policy Commission report. “It basically acted as a third-party validator to the hospital position on cost.”
Stuart Altman, the chairman of the Health Policy Commission, said the idea to carry out an analysis of the ballot question grew out of conversations he had in the spring with the commission’s executive director, David Seltz, and several members of the commission.
“The Health Policy Commission was set up to look at all the major [health care] cost drivers and access drivers in the state,” said Altman. “I thought it would have been irresponsible if we hadn’t done it,” he said of the analysis.
The Health Policy Commission issued a request for proposals on July 5 to hire an outside expert to aid in an analysis of the ballot question, and on August 14 it struck an agreement to have Joanne Spetz of the University of California, San Francisco, work with the commission’s research director, David Auerbach, on the report.
Julie Pinkham, executive director of the Mass. Nurses Association, and Steve Walsh, president of the Massachusetts Health and Hospitals Association, both sit on the Health Policy Commission’s advisory council, a panel of health care stakeholders.
Pinkham said there was no indication given to the union throughout the summer that the commission had in fact launched such a study.
At the advisory council’s September 5 meeting, she said, Walsh requested that the Health Policy Commission convene a panel discussion on Question 1 as part of its annual cost trend hearings in October, and she agreed that such a conversation among experts on both sides would be healthy.
In hindsight, Pinkham said it is outrageous that Seltz, the Health Policy Commission executive director, engaged in a conversation about planning a panel discussion without disclosing that an analysis of the ballot question was underway.
“It’s a sin of omission,” she said. “They blatantly hid this from us.”
Three weeks later, on September 24, the Health Policy Commission announced that it would present findings from an analysis of Question 1 at an October 3 meeting.
The commission declined to make Seltz available for an interview, but said he never misled anyone by making any “affirmative comments regarding a potential analysis on nurse-to-patient staffing ratios” before the public announcement of the report.
Altman said the commission’s standard practice has been not to announce ahead of time analyses it is carrying out.
The nurse staffing report, however, put the commission in the awkward position of reaching out to the hospital association for data on nurse staffing needed for the report, even though the hospital organization represented one of the two sides battling it out in the ballot question campaign.
“Where else are you going to get the data?” asked Altman. “There’s no hidden agenda here. We think we did an objective job.”
Apart from reaching out to obtain staffing and patient census data, Altman said, “we didn’t confer with anybody from the hospital industry.”
He scoffed at the idea that the Health Policy Commission would favor the hospital side, pointing out that the commission threw a huge roadblock up in 2013 to plans by Partners HealthCare to acquire South Shore Hospital. “They were ready to kill us,” he said.
Donald Berwick, a member of the Health Policy Commission board and a nationally-recognized expert in health care quality, safety, and costs, said the nurse staffing analysis was a responsible effort to address important questions.
“The process, as I saw it, was done with diligence and honesty and skill,” he said. “I know it was a very contentious debate, and there are good arguments on both sides.”Pinkham said the Mass. Nurses Association had criticisms of how the study was conceived and what data were used, but had no opportunity to give that input at the outset. She said an even-keeled analysis would have demanded that Health Policy Commission officials speak early on with the nurses’ organization, just as it reached out to the hospital association.
“It turned out to be a very bitter pill,” she said.