Advocates, foes of Question 1 look to the west

Oct. 28--Both the nurses union that supports the Question 1 ballot initiative to mandate nurse-patient staffing ratios and the hospital executives opposing it are looking west to California in their final pitch to voters.

But both sides draw very different conclusions about the impact of the California law passed in 1999 and enacted in 2004. The law made California the first state to call for mandated staffing ratios.

"California hospitals have closed, and our health care is better," said Michael Lauf, president and CEO of Cape Cod Healthcare, which employs nearly 1,000 nurses in its two hospitals.

The Coalition to Protect Patient Safety, which includes the Massachusetts Health and Hospital Association, the Massachusetts Medical Society and dozens of other organizations of health care professionals, issued a statement saying the California law resulted in dramatic increases in wages that hurt hospitals with lower operating margins and resulted in increased waiting times in emergency departments, among many other things.

Kate Norton, a spokeswoman for the Committee to Ensure Safe Patient Care -- which includes the Massachusetts Nurses Association that wrote Question 1 -- strongly disagrees.

"It's a scare tactic for voters," Norton said of the statement by the coalition.

Insurance rates in California dropped to lower than the national average and lower than Massachusetts, Norton said.

Several studies indicate better patient outcomes, Massachusetts Nurses Association officials said.

"Better patient care is more cost-effective than poor patient care," Norton said.

Both sides are accusing the other of blatant mistruths, with Judith Shindul-Rothschild, a nursing economist at Boston College and past MNA president, saying she was "absolutely shocked" by the Coalition to Protect Patient Safety's "holding the wall" commercial that showed first responders waiting longer in California for their patients to get hospital care.

"The California (emergency department) wait times are less than ours," Shindul-Rothschild said.

The Centers for Medicare and Medicaid Services statistics for 2016-2017 say the average wait time in Massachusetts is 32 minutes, compared with 22 minutes in California, Shindul-Rothschild said.

"A number of benefits have been extremely well-documented," said Deborah Burger, a registered nurse at California's Kaiser Permanente Santa Rosa Hospital.

A 2010 study of patient outcomes by Linda H. Aiken at the University of Pennsylvania showed there were fewer complications, Burger said.

A study by Shindul-Rothschild of readmission rates for heart failure and pneumonia in three different states showed California leading the way.

"One of the factors that lowered readmission rates was simply to be hospitalized in California," Shindul-Rothschild said.

But according to many other studies, "There is no conclusive research that shows mandated staffing ratios resulted in improved patient care," said Jan Emerson-Shea, spokeswoman for the California Hospital Association.

"The jury is mixed," Emerson-Shea said.

Any improvements in patient care could also be attributed to quality initiatives rolled out in the wake of a 1999 Institute of Medicine report, "To Err Is Human," that quantified hospital deaths from medical errors, Emerson-Shea said.

"It's impossible to pull apart which is more attributable to quality of care," Emerson-Shea said.

Executives of Cape Cod and Falmouth hospitals say they fear the cost of hiring what they estimate to be an additional 250 nurses to meet staffing ratios would hurt the services currently provided.

California nurse salaries rose 7 percent -- an increase that would have a big impact on the local hospital system, where most reimbursements come in the form of Medicaid and Medicare, Lauf said.

"We don't have the payer mix of Boston and Hingham," Lauf said.

A 2011 study by Emi Terasawa of the Analysis Group. Inc. in New York appears to justify some of those fears.

"My research found that California's nurse staffing mandate was associated with a significant increase in hospital and emergency department closures," Terasawa said in an email.

The trend was particularly pronounced in California hospitals that had low nurse staffing ratios prior to the law being passed, and which had to incur greater staffing increases, Terasawa said.

Those hospitals tended to have had a higher county percentage of patients with no health insurance, among other characteristics, she said.

Even though the California Hospital Association opposed the nurse staffing mandate, the organization doesn't put the onus for hospital closures on the mandated nursing ratios, Emerson-Shea said.

"Ratios certainly contribute to the financial challenges," Emerson-Shea said, "but it would not be fair to say ratios in and of themselves led to closures."

Underfunding of Medicaid, the state requirement to build earthquake-proof hospitals and other financial pressures are among the factors that led to hospital closings in California every year, Emerson-Shea said.

The Coalition to Protect Patient Safety not only points to what it perceives as problems with the California law, it says the Massachusetts nursing initiative is more stringent, with $25,000 fines and and tighter nurse staffing ratios.

While the California law calls for staffing ratios of one nurse per five patients on medical-surgical floors, according to Emerson-Shea, Question 1 calls for one nurse per four patients in the medical-surgical unit.

MNA spokesman David Schildmeier contests the coalition's statements, saying: "There are no automatic fines, period. Each violation is investigated and the HPC (Health Policy Commission) has complete discretion to issue no fine."

It also will take time to develop the regulations regarding compliance, Schildmeier said, disputing a coalition statement that fines could start as soon as Jan. 1.

It's not only the study of California patient outcomes that proponents and opponents of Question 1 disagree about.

While the Health Policy Commission, an independent state agency, estimated it would cost up to $949 million to put staffing ratios into effect if Question 1 passes the Coalition to Protect Patient Safety put that price tag at $1.3 billion while the MNA placed the cost at $47 million.

Shindul-Rothschild, who came up with the MNA estimate, said she did not include the cost of nurse recruitment because that is already ongoing.

And she said the Health Policy Commission calculated wage inflation too high, at 4 percent to 6 percent for all 80,000 registered nurses in Massachusetts, when only 24,000 work bedside at hospitals.

"I'm not getting any 6 percent wage increase from Boston College any time soon," Shindul-Rothschild said.

Estimates of cost need to take other factors into consideration, such as a 2015 study that showed that the rates of occupational injuries among nurses in California dropped after staffing ratios went into effect -- which is a cost savings in and of itself, she said.

Currently, nurses at Cape Cod Hospital -- especially in the medical-surgical unit -- are under a lot of stress, said registered nurse Shannon Sherman of Yarmouth Port.

Sherman, who is the grievance chairwoman for the Cape Cod Hospital chapter of the Massachusetts Nurses Association, said she recently moved from the medical-surgical floor on Mugar 5 at Cape Cod Hospital to the post-anesthesia care unit because of the smaller patient load in that unit.

"I was considering leaving Cape Cod Healthcare because it was so bad at the bedside," Sherman said. "I just couldn't take it any longer."

In Massachusetts, the only nurse staffing ratios required by law are in critical care -- which Sherman said includes the post-anesthesia care unit -- where legislation that went into effect in 2016 requires one nurse for every one or two patients.

In the post-anesthesia care unit, Sherman said she is limited to two patients, while on Mugar 5 she had an average of five post-surgical patients.

"The nurses up on Mugar 5 very rarely get any of their breaks" and if they do, they take them on the floor, Sherman said.

"It's high tension," she said.

-- Follow Cynthia McCormick on Twitter: @Cmccormickcct.

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