“Back of Envelope” Study Reaches Inaccurate Cost Conclusions

A nurse ratio cost study that the Massachusetts Nurses Association released last week has been described as academically and scientifically unsound and grossly underestimating the true cost of mandated nurse staffing ratios.

MNA’s “back-of-envelope” calculation is that the cost of implementing ratios would be, at most, $46 million annually – a figure that was immediately decried as being divorced from available data. The Commonwealth of Massachusetts has determined that the cost of ratios at seven hospitals operated by the Department of Mental Health alone would be $46 million annually. The Mass. Association of Behavioral Health Systems found that ratio costs at free-standing psychiatric hospitals and substance use disorder facilities would be an additional $100 million annually.

Other studies have used current, detailed staffing and patient volume data – which hospitals report publicly by shift and by unit on Patient Care Link – and then included additional refinements relating to mandated acuity tools, break and meal time for RNs, patient volume surges, and more. By comparison, the MNA’s cursory study makes comparisons between the RN-to-total hospital personnel ratio in California versus Massachusetts. (California is the only state with mandated ratios and the evidence there shows that there has been no meaningful improvement in patient outcomes as a result of the mandate.) Comparing California to Massachusetts, as the MNA did, is the classic apples-and-oranges analogy. The Massachusetts proposed ratios are stricter than the ones in place in California, where the law also allows LPNs to be counted in its ratios. (The Massachusetts ratio proposal is limited to RNs only.) California offers waivers from the law to certain rural hospitals and does not impose non-compliance penalties, while Massachusetts hospitals failing to comply with the at-all-times, all-hospitals ratios would face fines of up to $25,000 per incident, per day.

A sophisticated study conducted by Mass Insight and BW Research Partnership found that ratios would cost $1.3 billion in Massachusetts the first year and nearly $1 billion annually thereafter. That detailed study included the following factors, among others, that the MNA study completely ignored:

the cost of implementing acuity tools;
the cost of implementing ratios in operating rooms, post-anesthesia care units, pediatrics and rehab units, maternity units and post-acute hospitals. (These units were excluded from the MNA study);
wage inflation, which was 8 to 12% in California after passage of the ratio law;
ratios’ effect on non-hospital settings and additional state spending; and
the cost of recruitment, training and turnover.

Even through the MNA study is fatally flawed and tilted, it still finds that nine Massachusetts hospitals currently operating in the red will fall deeper into debt if the ratio law passes.
“Even in the union’s best case scenario, they acknowledge community hospitals will be pushed over the financial edge,” said Dan Cence, spokesperson from the Committee to Protect Patient Safety. “They simply do not care.”

The study was created by Judith Shindul-Rothschild, who is a former MNA president and current associate professor at Boston College. She noted in the flawed paper that the views within it are hers alone and not those of Boston College.