Wall & Main: How to vote on Question 1?
On Nov. 6, Massachusetts voters face a decision on Question 1, a ballot question that would regulate the ratio of nurses to patients in health care facilities.
After watching dueling TV advertisements on this question — one of three on the ballet — I have some questions of my own: What is Question 1? What is the problem Question 1 is designed to solve? What is the best solution to the problem? Is a “yes” vote the right solution?
Question 1 asks voters to approve a proposal on which the Massachusetts House did not vote last May. The proposed law would limit the number of patients assigned to each registered nurse in Massachusetts hospitals and some other health facilities, according to the secretary of the commonwealth of Massachusetts.
The ratios of patients to nurses would vary depending on the department within the health facility. For example, in the emergency services department, the law would require a 1:1 ratio of critical or intensive care patients per nurse.
The proposed law would have many other provisions — most notably, that a covered health facility would need to post the details of the patient assignment limits and the facility would be fined between $250 and $2,500 a day for noncompliance with the law.
If most voters say “yes,” the proposed law would go into effect on Jan. 1, if “no,” the current law would remain state law. Currently Massachusetts law specifies nurse-to-patient ratios only in Intensive Care Units, but some specialties have recognized guidelines, and some health care providers have ratios in their labor contracts.
It is unclear to me what problem Question 1 is intended to solve.
Could it be to improve on declining patient satisfaction with the state’s health care system? The most recent survey of patient satisfaction that I could find suggests that things have gotten better over the last three years from the patient’s perspective.
According to the January 2018 survey of commercially insured Massachusetts patients in primary care conducted by Massachusetts Health Quality Partners — whose board consists of hospital executives — “patient experiences over the past three years across all topic areas explored in the survey for both adult and pediatric care — communication, integration of care, knowledge of patient, adult behavioral health, organizational access, self-management support, office staff, pediatric preventive care, child development, and willingness to recommend — have continued to improve.”
After all, from my own experience in the health care system, I know that nurses can have a huge effect on a patient’s experience. So, it stands to reason that higher levels of nurse job satisfaction should result in higher patient satisfaction.
Yet Question 1 is being supported by the Massachusetts Nurses Association (MNA), a labor union, which argues that such limits would allow nurses to provide safer care to patients.
And a recent survey of Bay State nurses makes me think that that they are under increasing stress. The MNA cites an April 2018 survey of Massachusetts registered nurses by the Committee to Ensure Safe Patient Care (CESPC), which found a sharp rise in the number of nurses reporting patient deaths “directly attributable to having too many patients per nurse.” That percentage has risen from 23 percent of nurses citing such deaths in 2013 to 36 percent in 2018, according to that CESPC survey. The survey also found that 77 percent believe that RNs are assigned too many patients to care for at one time.
I am probably like most readers in not wanting to be a patient who dies due to over-stressed nurses.
Yet adding more nurses will cost more money. And there are widely diverging estimates of how much more money:
The Massachusetts Health Policy Commission, an independent state agency charged with monitoring health care spending, says Question 1 will cost between $676 million and $949 million per year to hire from 2,286 to 3,101 additional full-time nurses to comply with the ballot measure. However, a study cited by MNA says the law will cost about $47 million more annually — 14 times less than the commission’s estimate.
Ms. Pinkham also struck a note of fear. On Oct. 4, she said in a press conference, “If I have four patients and you put on your call button, I can get to you. If I have eight, you wait. What happens when you wait? Sometimes something bad happens.”
On the other hand, a “yes” vote on Question 1 could lead health care providers in less populated regions of the state to cut unprofitable services to offset the cost of hiring more nurses.
Not all nurses agree with Ms. Pinkham’s view that more nurses will boost the quality of patient care. In an Oct. 9 interview, Teresa Rincon, RN, PhD, the Director of Clinical Operations/Innovation, TeleHealth for UMass Memorial Health Care, said, “Question 1 implies that hospitals in Massachusetts have a problem with providing safe patient care today and need to follow the example of California to improve. Studies demonstrate that quality of care did not systematically improve after California implemented mandated nurse staffing ratios.”
Ms. Rincon would rather see an improvement in the work environment for nurses and more highly educated nurses. “UMass Memorial Health Care has identified that they can improve in this area and have begun a campaign based on standards of respect. Many Massachusetts hospitals and health systems have also started shared governance councils and idea systems that honor and reward the ideas and input from all healthcare providers, including nurses. Another way to improve quality of care is to hire more nurses with bachelor’s degrees in nursing,” she said.
My conclusion is that a “yes” vote on Question 1 would force state health care providers to quickly hire the mandated number of nurses — a move that would certainly cost hospitals more without necessarily improving the quality of patient care.
Peter Cohan of Marlboro heads a management consulting and venture capital firm, and teaches business strategy and entrepreneurship at Babson College. His email address is peter@petercohan.com.
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