Decision time looms on Question 1: Mandatory nurse staffing levels for hospitals


In the Berkshires, Election Day rings in Round 2 of the fight to decide the merits of a beef between registered nurses and Berkshire Medical Center.

This time, county residents share the puzzle with all Massachusetts voters — and voters alone will answer it.

Question 1 on the statewide ballot asks voters to settle elements of the staffing dispute that kept union nurses at BMC at odds with management for parts of three years. The contract that members of the Massachusetts Nurses Association signed this spring in Pittsfield did not limit the number of patients that RNs can be asked to handle, one of their early demands.

But Question 1 would.

The measure would set maximum patient numbers per nurse in Massachusetts hospitals, starting Jan. 1, depending on where care is delivered and on a patient's condition. Violations could trigger $25,000-a-day fines.

Proponents say registered nurses are asked to take on too many hospital patients, diminishing the quality of the care they receive. They claim that the ballot question, shaped by the MNA, will cost less than $47 million at the outset and can be paid for by cutting executive salaries.

Opponents say hospital care teams need flexibility in how they assign nursing care and that Massachusetts hospitals already rank higher in care quality than California, a state that uses staffing ratios. They claim that the measure would cost $1.3 billion to enact in its first year, lead to longer waits for care and might force small hospitals to close.

As TV spots and robocalls flow, engaged residents continue to hear dramatically different forecasts about what has emerged as the ballot's most contentious referendum question. The challenge for voters is to decide which argument is best supported.

Massachusetts law allows voters to set policy through the referendum process. Efforts to secure nurse-patient ratios have failed to advance in the Legislature, except for a law that spells out required nursing staffing in intensive care units.

Proponents ask: Whom do you believe, rank-and-file nurses at the bedside forced to care for increasingly sicker patients or fat-cat hospital execs?

"Anybody that works in a hospital and does patient care knows how important this ballot question is for Massachusetts," said Amber VanBramer, a union RN in Pittsfield. "We need a law in place so that there are no questions. If we have a law, we're protected. It's disheartening to choose which patient you put on the bedpan first and which one you have to clean later."

Yes, whom do you believe, opponents ask: Union nurses who stand to see the market value of their labor rise as hospitals scramble to hire amid shortages or an independent state panel?

"I worry about the financial impact this question could have," said Dr. Michael McHugh, BMC's chairman of emergency medicine. "That's what terrifies me most. The team approach provides us some flexibility in ways that the ratio wouldn't allow us to. It provides us with the right mix of individuals working to the top of their degree."

Ready to vote? If not, chances are you're not alone.

From now to Tuesday, expect rhetoric to heat up on both sides, as opponents of Question 1 press their financial advantage in campaign financing and continue heavy spending on television ads, including one that features a man with heart disease who suggests that the measure puts his life at risk.

Answers elusive

Unfortunately for voters, existing academic research or independent reports do not appear to provide a clear verdict. Two studies cited prominently by the camps were not arms-length efforts; one funded by the Massachusetts hospital trade group and another written by a Boston College economist with ties to the MNA.

California regulates nurse staffing, raising the hope that its experience could inform the Massachusetts debate. But when California lawmakers passed a law in 1999 that set nurse-to-patient ratios, their measure asked a state agency to figure out the right staffing numbers, roll out new policies over time and include the work of nurses with other training, not just RNs.

The two states can't be directly compared because the Massachusetts proposal would set lower nurse-patient ratios in some instances — raising its cost and impact on health — and does not provide a waiver for rural hospitals.

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In early October, the state's Health Policy Commission, which serves as the prime watchdog on health care costs, weighed in with a report estimating that it would cost hospitals $676 million to $949 million to comply.

That range would represent 1.1 to 1.6 percent of the total spent annually on health care, the panel estimated. Separately, a study by MassInsight and BW Research Partners commissioned by the hospital industry found that the question would add $1.3 billion in costs for hospitals in its first year, then $900 million a year after that. The measure would take effect Jan. 1.

For Berkshire Health Systems, the question would add $24 million in yearly costs, according to David Phelps, its president and CEO, mainly triggered by what it says will be the need to hire 125 full-time-equivalent RNs.

The Health Policy Commission's cost range factored in what it said would be $34 million to $37 million in savings due to shorter hospital stays and better patient outcomes due to increased nurse staffing.

The state commission's cost estimate is 14 to 20 times higher than the $47 million first-year cost that proponents predict if the question passes.

A report commissioned by the MNA and conducted by Judith Shindul-Rothschild of Boston College said Question 1 would require hospitals to add 539 to 1,617 nurses. The count that arrived Oct. 3 from the state commission was as much as four times higher — in the range of 2,286 to 3,101 new hires.

Julie Pinkham, the MNA's executive director, assailed the commission's report. Proponents of Question 1 accused the state group of bias in favor of the hospital industry.

Costs aside, the commission's report, compiled by David Auerbach, its research director, and Joanne Spetz, a University of California professor, said that as of 2016, Massachusetts hospitals had higher nurse staffing levels even without a mandate than California, which had such a law.

Further, their report said that on five of six measures of quality linked to nursing — one example given was infections of surgical sites after colon surgery — Massachusetts hospitals performed better than those in California.

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Panel's hearing

The state commission followed up with an Oct. 17 hearing that drew expert testimony on both sides, much of it related to California's experience with staffing ratios.

But even that airing of clinical outcomes and research included debate.

Vicki Bermudez, a policy analyst with the California Nurses Association, told the commission that two years after her state's new staffing rules went into effect, benefits were being seen.

"The better staffing demonstrated significantly lower mortality," Bermudez said, referring to a study comparing California with two other states.

"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."

Spetz, the California professor who has advised the Massachusetts commission since August, countered that the lower surgical deaths cited by Bermudez could not be proved to be the result of nurse staffing levels.

"That was correlational," she told the panel. "The papers that have tried to use approaches that identify causal relationships have found no consistent patterns with the data that are available."

While cause and effect might elude scientific proof, another expert, Shindul-Rothschild, the Boston College researcher with past ties to the MNA, told commissioners it is "indisputable" that having more nurses available improves patient care.

Berkshire voices

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Locally, the fight over Question 1 has sprouted a whole new crop of battling lawn signs, perhaps none more dramatic than the two supersize messages that greet westbound Pittsfield travelers on Tyler Street at the First Street intersection.

Over the past few weeks, The Eagle has published dozens of letters and opinion columns arguing for and against the ballot question, many of them reprising voices heard during the MNA's drawn-out contract negotiations.

In interviews with The Eagle, some of those familiar voices sought to boil down the merits of their side.

Mark Brodeur, an RN and member of the nursing union's bargaining committee, suggested that the issue is simple: "Making sure the patients are getting the care they deserve and that they need."

Brodeur said that hospitals in Massachusetts, including BMC, can afford to pay to employ more RNs.

"We have the resources needed," he said. "It will cost money. That's no secret. They will have to invest in nursing staff."

Brodeur refutes predictions from Question 1 opponents that hospitals won't be able to find the RNs they would need to increase staffing.

Darlene Rodowicz, the chief financial officer at Berkshire Health Systems, said the institution would have to hire as many as 125 new full-time-equivalent RNs; it employs about 800 now.

She dismissed calls by the MNA that the expense of hiring additional RNs could be offset by administrative cost-cutting.

"I don't see that we'd be able to reduce those positions," Rodowicz said, adding that administrative ranks are not "staffed very richly."

"We're really going to have to look at all of our services if this goes through," she said.

Kate Norton, the spokeswoman for the Committee to Ensure Safe Patient Care, which backs the question, said hospitals have offered skewed estimates of what the measure would cost.

"We're not seeing any kind of data to support what we feel are inflated numbers from the opposition," Norton said. A 3 percent cut in administrative costs would cover new RN expenses, she said.

"You put that toward direct care and you're good," Norton said. "The notion that the sky is falling is just fallacy," she said.

Dr. Daniel Doyle, BMC's chief of staff, said he is worried about how BMC would recruit the number of new RNs it would need under new ratios.

"We already find it challenging to staff RNs here. It's going to be impossible to find 100 nurses," he said. "This is an effort through the ballot question to achieve what cannot be achieved through collective bargaining."

VanBramer, the RN who helped her union negotiate its latest contract in Pittsfield, acknowledged that voters are being asked to decide a complicated issue.

"You should read the bill and make the decision about what you feel is right," she said of voters. "You need to be informed."

Larry Parnass can be reached at, at @larryparnass on Twitter and 413-496-6214.


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