10.22.2018

Q1 Costs, Workforce, Endorsements, Editorials & more ...

HPC Impartial Review of Mandated Ratios Paints Bleak Picture

The state’s Health Policy Commission devoted part of its two-day cost trend hearing last week to the Question 1 ballot issue, adding new insight into the staffing mandate’s costs, workforce requirements, effect on behavioral health, and more.

“To be absolutely honest with you, if this passes, what I will focus on in November and December is closing areas” of Boston Medical Center (BMC), said Nancy Gaden, R.N., DNP, BMC’s Senior V.P. and Chief Nursing Officer. Gaden testified that because of workforce shortages and the tight implementation date, she would need to close about one third of labor and delivery beds, forcing about 800 mothers a year to seek other facilities in which to deliver. Gaden said those expectant mother would most likely travel out of state since other Massachusetts hospitals would be faced with the same problem staffing labor-and-delivery positions.

Implementation Date
The HPC last Wednesday ended the false debate about when Question 1 goes into effect. The MNA has been trying to argue that the nurse staffing law’s implementation will be similar to the delays associated with putting the recreational marijuana law into effect. But those two laws are written differently. At last week’s HPC hearing, a former MNA president even said that she had been told by a DPH representative that implementation would be delayed from the January 1, 2019, date specified in the law. (She was quickly informed that the DPH worker she talked to was an ex-employee and wasn’t speaking in any official capacity.) So when will Question 1 go into effect if passed? The HPC’s General Counsel Lois Johnson told the commissioners: “The effective date is January 1, 2019.” That will give hospitals 36 business days to hire the approximately 5,900 nurses required by the law, as well as installing mandated acuity systems in all units.

Workforce
There is a current nursing shortage in Massachusetts and the RNs needed to fill the government-mandated ratios in 36 days do not exist. Former MNA President Judith Shindul-Rothschild, a Boston College associate professor, said current RNs who are not working would flock back to their jobs if conditions improve. “If you staff it, they will come,” she told the HPC. But HPC Commissioner and Health & Human Services Secretary Marylou Sudders said the state has a new, licensed behavioral health facility in Westborough geared to children on the autism spectrum, but can’t open it because there are not enough RNs to staff the beds. “I’m talking about a state-of-the-art, brand new, free-standing psychiatric hospital for children on the spectrum. Can’t find a nurse. Brand new,” Sudders said. “There is licensed capacity but not staffed capacity because of the inability to hire nurses. It’s not a debate. It’s a reality.”

$949 million + $110 million = $1,059 BILLION
The HPC’s thorough research from two weeks ago pegged the cost of Question 1 at up to $949 million annually. But that figure did not include the cost to staff emergency departments (EDs) under the ratio law, which specifies four different ED ratios based on patient acuity. Commissioners told their research staff to take another shot at determining the ED costs of Question 1 implementation and last Wednesday Chief HPC Researcher David Auerbach, PhD, presented his findings. Auerbach said it is tough to arrive at a confident figure because much depends on patient acuity, but that the ED cost – over and above the already forecasted $949 million cost – probably would be between $79 million and $110 million annually. That $1 billion-plus annual cost of Question 1 does NOT include the cost of implementing acuity systems, the costs to outpatient departments, and, most importantly, the costs to non-acute hospitals.

Gov. Baker Says Question 1 Will Harm Massachusetts Healthcare

Governor Charlie Baker has announced that he will vote NO on Question 1, saying his decision was based on the Health Policy Commission report of the ballot question’s nearly $1 billion annual cost, as well as his discussions with healthcare community members who said Question 1 threatened their very existence.

“I had heard from many of my colleagues in the community healthcare space that many community hospitals and some nursing homes, and even some rehab hospitals would have their operational future put in jeopardy if this law passed – and many of those community hospitals are critical care access provider in their districts,” Baker said.

Baker is running for re-election against Democrat Jay Gonzalez, who was Governor Deval Patrick’s budget chief and most recently served as president & CEO of CeltiCare Health. Governor Baker also has strong healthcare credentials; he served as Secretary of Health and Human Services under Governor William Weld and as CEO of Harvard Pilgrim Health Care.

The HPC initially found that Question 1 would cost up to $950 million annually, but noted that this is conservative as it does not include the cost of implementation in the emergency department, outpatient, and observation units. The $950 million also does not include the cost of acuity tool implementation, turnover costs, and the cost to non-acute facilities, which when totaled would increase Question 1’s cost to well over $1 billion annually.

Speaking of his discussions with providers, Baker said, “The one I visited most recently was Harrington [Hospital] in Southbridge. They are the community-based provider, the emergency service provider, the mental health provider, substance use disorder provider, primary care provider in about 40 communities in Central and Western Massachusetts. And they said to me that they would have a heck of a time, and that they did not believe they could implement the law if it were to pass as written. That set off a bit of an alarm bell for me. So I’m going to vote No on Question 1.”

Behavioral Health is at Risk from Question 1

Behavioral beds will close if Question 1 passes and there are not enough RNs available to fulfill the staffing mandates contained in the ballot question. Those were the conclusions voiced by behavioral health experts at a media event held last Thursday at Franciscan Children’s Hospital in Brighton.

But a more disturbing fact that the experts voiced focused on how patients at risk would be affected by the massive disruption to the behavioral health system.

Michael Botticelli, executive director of the Grayken Center for Addiction at Boston Medical Center, said while the state has made the effort to expand treatment services, it has faced difficulty in finding nurses to fill needed posts within those services.

As a result, Botticelli said, “Question 1 could have significant consequences  in creating longer waiting lists for treatment, fewer admissions for people seeking treatment and most consequently program closures … We know that given the significant overdose risk for people in the commonwealth that we will only exacerbate our overdose death problem.”

Botticelli served as Director of National Drug Control Policy at the White House under President Obama.

Aimee Carew-Lyons, Chief Operating Officer & Chief Nursing Officer at Franciscan, said Question 1 would most likely result in the closure of one-third of the facility’s beds, thereby denying treatment for hundreds of at-risk kids.

Also decrying Question 1 were Vic DiGravio, President & CEO, Association for Behavioral Health; Barbara Green, Medical Director, Youth Health Connection, and  Co-Founder, Center for Integrative Counseling & Wellness; and Joanne Grady-Savard, Executive Director, Cole Resource Center.

Cast Your Ballot TODAY Against Question 1

Early voting in Massachusetts begins today, Monday, October 22. You can vote at the early-voting location in your town, or you can vote by mail. If you are against Question 1 – and why wouldn’t you be? – you can, beginning today, cast your ballot. Learn all the details of the hows and wheres by visiting the Massachusetts Secretary of State’s early voting page here.

Independent Poll: Nurses Split on Q1; MNA Poll Off by 40%

Just as the HPC put the Question 1 cost debate to rest, recent independent polling from WBUR has finally punctured the MNA’s claim that nearly all nurses support the ballot question.

The WBUR poll from October 5-10 found a near dead heat, with 48% of surveyed nurses saying they’d vote yes, and 45% voting no, with a margin of error of 4.4%.  Interestingly, 33% of the RNs surveyed were MNA members.  The Yes on 1 campaign had based much of its campaign on the inaccurate claim from its own poll – taken before Question 1 was even on the ballot – that 86% of nurses support Question 1. That poll has now been proven to be off by approximately 40 percentage points; the MNA’s cost estimate of Question 1 now has been proven to be off by approximately $950 million annually. The trend of spreading miscommunication continued later in the week, as the Yes on 1 committee was forced to concede its advertisement “misrepresented reporting done by the State House News Service,” according to the news service. 

Wall Street Journal Weighs in on Question 1

It’s rare that a state-specific ballot question garners national attention, but because Question 1 holds the promise of such negative consequences, the Wall Street Journal last Thursday penned an editorial entitled: “Bad Bedside Manner in Massachusetts.”

“Massachusetts has some of the best medical care in the world, but a ballot measure next month could start its erosion by raising costs and reducing access,” the Journal editors wrote. “… ‘I never want to come into work and have to deliberate whether or not I will be able to legally care for my patients,’ Sturdy Memorial nurse Meghan Aldrich says. ‘If Question 1 passes, I will constantly be faced with a moral dilemma—to break the law and provide care outside of my ratio, or let a patient suffer.’ … Voters – future patients nearly all – have every reason to reject Question 1.”

The full WSJ editorial is here.

Big Union Withholds MNA Ballot Endorsement

If Question 1 passes it will transfer $1 billion to a single component of the healthcare system – RNs – while resulting in service closures, increased insurance premiums, potential hospital shutdowns, and layoffs of other members of the hospital workforce. The union that represents many members of that non-RN workforce – Service Employees International Union (SEIU) – said last week it is staying out of the Question 1 debate and is not endorsing either side.

The Public Health Implications of Question 3

The Massachusetts Health & Hospital Association (MHA) was an early endorser of the Yes on 3 campaign for a variety of reasons, including the association’s vehement opposition to any form of discrimination. But there are clear public health reasons for voting yes on 3.

A yes vote on Question 3 supports upholding Chapter 134 of the Acts of 2016– existing law that prohibits discrimination based on gender identity in public places, such as hospitals, hotels, restaurants, and stores.

Transgender people are more likely to face acts of violence than non-transgender people, and because they are frequently attacked, bullied, and marginalized, transgender men and women are at higher risk for suicide, among other health concerns. The health of our society’s transgender members is at risk because of the discrimination that Chapter 134 seeks to eliminate. It is for these health reasons, as much as for the fundamental reasons of opposing discrimination, that MHA supports Yes on 3, upholding the state’s transgender anti-discrimination law.

John LoDico, Editor