Why we’re voting no on Question 1

SHOULD MASSACHUSETTS establish mandated nurse-to-patient ratios in law for all the state’s acute care hospitals? This 25-year-old conflict between the Massachusetts Nurses Association and Massachusetts Hospital Association will be determined at the polls on November 6 as Question 1.

We think not.

We are university professors who care about Massachusetts health care policy. We both connect with Massachusetts’ leading health care consumer advocacy organizations who worry about access, cost, and quality in Massachusetts’ health care system—and we don’t speak for them.

We have advocated publicly for better pay, working conditions, and training for health care workers in hospitals and nursing homes. We know the vital importance of organized labor as representatives of health care workers to meet their needs and to promote a higher quality care for patients. We are not eager to take a position opposed to the Massachusetts Nursing Association.

After seeing data advanced by groups on both sides, especially data and analysis from the Massachusetts Health Policy Commission, we believe the evidence, the better policy choice, and the more socially just result—especially for lower income households and communities—points to a no vote. The Legislature should demand that both sides come together to create a more workable set of solutions to improve quality of care in our state’s hospitals.

Here is how the evidence looks to us:

Health care costs

The Health Policy Commission report concluded that Question 1, if passed, would increase health care costs in our state between $676 to $949 million annually to meet the new “at all times” staffing requirements. The commission noted that this estimate may be conservative because it does not include additional nurse staffing costs for emergency departments. The estimate assumes salary for 2,286 to 3,101 additional nurses needed to meet Question 1’s inpatient staffing requirements, and wage increases at hospitals and other providers (such as community health centers and physician practices) to retain nurses as hospitals try to hire them away.

The commission estimates quality-related savings from Question 1 of between $34 to $47 million, from reduced hospital length of stay and adverse events, a finding based on prior research. The agency also recognizes the potential for additional savings from reduced overwork and burnout that result in higher registered nurse turnover and work-related injuries.

The Massachusetts Nurses Association’s cost estimate comes from research by Professor Judith Shindul-Rothschild from the Boston College School of Nursing. She estimates that Question 1 would increase demand for new nurses by 539 to 1,617 per year, translating into $47 million of additional spending for the 539 figure. Shindul-Rothschild also predicts no wage increase-related spending in her estimate.

The Health Policy Commission estimate appears more realistic than does the Shindul-Rothschild one. The commission’s projected increase would make our already expensive health care system ($61.1 billion in 2017) more expensive, threatening the cost control targets that the state has maintained successfully since 2013. As those cost increases move through the system, they could trigger these effects:

1. Community hospitals and behavioral health institutions will be threatened financially and may need to close patient care units;
2. Pay increases for other hospital workers may be crowded out by nursing pay increases;
3. Community health centers and physician practices will experience financial pressures and may lose registered nurses to higher-paying hospitals and will need substantial wage increases to retain them;
4. Commercial health insurance premiums for businesses and individuals will rise. We know that lower income, commercially-insured patients bear a harsher burden from premiums and out-of-pocket costs; and
5. Massachusetts government will need to pay more for its state hospitals, for its state employees’ health insurance, and possibly for the MassHealth program.

Patient safety and quality of care improvements

The Health Policy Commission quality of care data focus on comparisons between Massachusetts and California hospitals which have operated under a nurse staffing law since 2004. The California law mandates nurse-to-patient staffing ratios less strict than the one envisioned in Question 1. A review of California data and studies led the Health Policy Commission to conclude “there was no systematic improvement in patient outcomes post-implementation of ratios.”

One surprise from the Health Policy Commission analysis is that Massachusetts hospitals already employ more nurses per inpatient day—without mandated ratios—than California hospitals since their 2004 ratio implementation. Massachusetts hospitals, without a staffing law, perform better on five out of six nursing-sensitive quality measures for all inpatients, and about the same as California hospitals on three measures tied to Medicare inpatients.

Officials with the Massachusetts Nursing Association argue that patient safety and quality will improve if our nurses have fewer patients on their shifts. Studies suggest that more restrictive nurse-to-patient ratios lead to better quality, though none have tested levels mandated by Question 1. Researchers from Beth Israel Deaconess examined the impact of a Massachusetts nurse staffing law that went into effect in 2015 for intensive care units only. They found no impact on mortality or complications in spite of stricter nurse-to-patient staffing ratios in hospital ICUs.

Nurse burnout, occupational health effects, and job satisfaction

The Health Policy Commission did not report on job burnout or stress. While literature exists on nurse burnout, health effects, and job satisfaction, it is difficult to interpret what benefits would result from moving to staffing levels required by Question 1.

Rather than embrace an up-to-$900 million annual experiment, the hospital industry should fund a center to undertake and commission research and quality improvement efforts. Priorities should include addressing factors that negatively impact occupational health and job satisfaction of all hospital workers, especially nurses, including staffing considerations. While nurses are not the only health care workers who feel burnout and stress from higher severity and complex patients, they deserve special attention and concern.

California is different

Comparing the California law with Question 1, other considerations arise. In California, the mandated nurse-patient ratios are set by regulation and can be adjusted administratively; Question 1 would place staffing ratios in statute, making adjustments contentious and difficult—by design. California law imposes zero monetary penalties on hospitals for non-compliance, while Question 1 would impose $25,000 fines for each and every violation per day. California’s law permits waivers, while Question 1 does not. California’s law gave hospitals time to prepare for new increased staffing requirements while Question 1 takes effect January 1, 2019, though the language in Question 1 is unclear on whether hospitals must meet the new staffing ratios by then. These are all notable differences.

In light of the recent Health Policy Commission report, it is ironic that the Massachusetts Nurses Association designated the agency to be the anointed implementer and enforcer of the new system. We wonder if the nurses association might prefer a redo on that feature. The commission’s “job one” is to watchdog state compliance with the benchmark health spending growth target established in 2012, which Question 1 now threatens to upend more than any initiative since the agency’s creation.

For 25 years, this grudge match between the Massachusetts Nurses Association and the Massachusetts Health and Hospital Association over nurse-patient ratios has endured without solution. The nurses association has now chosen to put the fight into the court of public opinion. Though our hearts are with the nurses, our heads can’t accept Question 1 as good public policy for Massachusetts. The Legislature should send both parties back to the public policy bargaining table.

Paul Hattis is a public health professor at Tufts University Medical School and a former commissioner of the Health Policy Commission and John E. McDonough is a professor of practice at the Harvard T.H. Chan School of Public Health. Elizabeth Sherman provided research assistance.