A discussion at a Health Policy Commission hearing illustrated the complexity of the issue, and the many unanswered questions, with both sides bringing statistics to bolster opposing viewpoints.
Dr. Stuart Altman, chairman of the Massachusetts Health Policy Commission, has been approached with questions about the November ballot question that would mandate nurse staffing ratios.
"I can't tell you the number of people who came to me who legitimately want to do the right thing and said we have no idea, why are you asking voters to make this kind of a complicated decision?" Altman said.
The ballot question would mandate specific nurse to patient staffing ratios that would vary by unit. Proponents say it would improve patient safety by ensuring hospitals are not understaffed. Opponents say the ratios are inflexible and costly, and would lead to closing units.
The Health Policy Commission, as part of its annual health care cost trends hearing Wednesday, held an hour-long panel discussion with representatives on both sides of the issue, including experts from California, the only state with mandated nurse staffing ratios.
The discussion illustrated the complexity of the issue, and the many unanswered questions. Both sides brought studies and statistics to bolster opposing viewpoints.
"I understand why voters are confused in Massachusetts," said commission member Tim Foley, vice president of 1199SEIU Healthcare Workers East.
One area of disagreement is whether hospitals would be able to hire enough new nurses to meet the ratios -- particularly in the short time frame allowed by the ballot question, which would go into effect Jan. 1, 2019.
"In 37 days, we could never staff up," said Boston Medical Center Chief Nursing Officer Nancy Gaden.
Gaden said if the ballot question passes, she would close beds in order to meet the requirements of the law. She said Boston Medical Center would likely have to close labor and delivery beds and turn away elective admission patients to medical units.
Gaden said she particularly worries about the emergency department and labor and delivery, areas that require specialized skills. Training new nurses for those departments takes six to nine months, she said.
Statewide, Gaden said there are 1,200 open nursing positions, a 5 percent vacancy rate. "We have a nursing shortage in Massachusetts," she said.
But Judith Shindul-Rothschild, associate professor at the Connell School of Nursing at Boston College, said Massachusetts schools graduate 2,400 nursing baccalaureate students annually, and new graduates have trouble finding work in Massachusetts hospitals.
"I'd love to know where those openings are, and so would our nursing students," she said.
Shindul-Rothschild said Massachusetts also has a high number of part-time nurses, and hiring them full-time would help meet the staffing ratios.
She noted that a federal study predicts that by 2030, Massachusetts will have a slight surplus of nurses.
Commission member Martin Cohen, president and CEO of the MetroWest Health Foundation, worried about what the question will mean for behavioral health treatment, given an existing shortage of psychiatric nurses.
Secretary of Health and Human Services Secretary Marylou Sudders said the state recently licensed a new, state-of-the-art psychiatric unit to treat children on the autism spectrum. "They can't open because they can't find nurses," Sudders said. "It's not a debate. It's a reality."
Shindul-Rothschild, a psychiatric nurse, said part of the problem is unsafe conditions for nurses. Safe staffing ratios could reduce days lost to workplace injuries, she said, and investing in scholarships or programs to improve conditions for psychiatric nurses would also alleviate shortages.
The core of the debate around nurse staffing is whether the proposed ratios will improve patient care.
"It's indisputable that better staffing levels lead to better patient outcomes," said Shindul-Rothschild.
Vicki Bermudez, a regulatory policy specialist from the California Nurses Association, said California's nurse staffing ratios "leveled the playing field for all hospitals" so that all patients are assured of quality nursing care. She cited studies showing that better nurse staffing ratios are tied to lower mortality rates.
But Dr. Joanne Spetz, professor at the Institute for Health Policy Studies at the University of California, San Francisco, conducted a study with the Health Policy Commission that found there was not a systemic improvement in patient quality in California after the staffing ratios were implemented.
While some measures saw improvement, Spetz said, "You couldn't say the improvements in patient outcomes were strictly due to the regulations being implemented."
The extra cost associated with the ratios is also disputed, with both sides presenting different figures. One question is where the money would come from.
Hospitals say they would have to close units, while ballot question advocates say hospitals could take money from their profits.
Deborah Devaux, chief operating officer for Blue Cross and Blue Shield of Massachusetts, which is not taking a position on the ballot question, said where the money would come from remains an "unanswered question."
"Some suggest hospitals could absorb some or all of the potential new cost. Hospitals disagree," she said. Devaux questioned whether government or consumers will have to pick up the costs, and whether it will become an "unfunded mandate."
Devaux said she could not answer a question about whether the insurer will increase premiums. The answer, she said, circles back to the issue of the available workforce and whether hospitals would respond to the ballot question by hiring nurses or cutting beds.
"We were not able to estimate the impact on premiums primarily because of unanswered questions about whether the hospitals would be able to hire and employ the nurses necessary," she said.
