Two Reports on RN Staffing: One Credible, One Not, and more...

ED Physicians & Nurses Describe Harm from Ratio Law

The Massachusetts College of Emergency Physicians and Emergency Nurses Association-Massachusetts State Council released a report last week showing that passage of Question 1 – the ballot question that would impose at-all-times nurse staffing ratios in all units of every hospital – would increase wait times in emergency departments (EDs) and exacerbate the current crisis of ED boarding.

The ratio scheme in the ballot question is particularly onerous for hospital EDs, as the proposed law would require four different, ever-changing ED nurse-to-patient ratios, depending on the status of the patient being treated.

“Patients’ conditions in an ED can change very quickly, with little warning,” the ED physicians and nurses wrote. “In order to maintain compliance with the mandated RN ratios, hospitals would need to constantly assess staffing assignments and reassign available RNs based purely on unproven, arbitrary mandates, regardless of whether there are other members of the ED team … who are capable and available to help.”

According to the study, “Instead of providing care based on clinical judgment, patients’ medical needs, and the skills, experience, and availability of the entire care team, hospitals would be forced to constantly scramble RN patient assignments to try to prevent the RNs from exceeding the mandated ratios. To ensure that hospitals have the resources to hire more RNs, many of the ED team positions would have to be eliminated, which would result in RNs performing medical services below their expertise that will further delay evaluation and treatment for other ED patients.”

Only one other state – California – has imposed government-mandated ratios on its health system, and the evidence from there shows that ratios have been detrimental to hospital EDs. California studies show that ED wait times increased following the implementation of mandated ratios, despite fewer people seeking care.

The read the entire report, including citations to the studies showing the harm to the California healthcare system, please click here.

“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.

In Memoriam – Timothy Francis Gens (1949-2018)

Tim Gens, a beloved friend and colleague to many, and an intelligent and creative leader within the healthcare community, passed away on September 10 after a nearly two-year battle with glioblastoma. He was 69 years old.

Tim was profoundly intelligent, compassionate, and dedicated to his work and family. He was also very, very funny. When you sat down to work with Tim, the nose-to-the grindstone activity would commence after you stopped smiling from his razor-sharp wit.

When he announced in December 2017 that he was stepping away full time from the office, a void was created at MHA – a sadness only amplified by his passing.

Tim was a “triple eagle” – a graduate of BC High, Boston College (BA, 1971) and BC Law (JD, 1975). Before his 23-year career at MHA where he served as Executive V.P. and General Counsel, Tim had an 11-year career as the MBTA’s planning, policy, communications, and intergovernmental affairs leader. Before the MBTA he was a passionate and progressive political consultant. (He had great stories about his days in the political trenches.)

At MHA, his vision and boundless energy led to groundbreaking advancements in public reporting of hospital data, a renewed emphasis on combating medical errors, and the seeds of payment and delivery system reform that resulted in the commonwealth’s historic Chapter 58 healthcare reform law in 2006, which, in turn, led to the national Affordable Care Act.

Tim is survived by his wife Madeline, his children Jamie Langley and her husband Merrill of Edgartown, and Kathleen and Dylan of Boston; his grandchildren, and other relatives.

Memorial contributions may be made in Tim’s memory to Bay Cove Human Services, 66 Canal Street, Boston, Massachusetts 02114 or The Literacy Project, 15 Bank Row, Suite C, Greenfield, MA 01301.

Tim made a difference. He will be missed, but remembered. Our hearts are saddened by his passing.

Healthcare Beats Benchmark – But Big Problem Looming

The state’s Center for Health Information and Analysis released its latest annual report on the performance of the Massachusetts healthcare system – and the picture it paints is a positive one.

According to the data, total healthcare expenditures per capita grew at just 1.6% from 2016 to 2017, with cost growth slowing across all services and remaining significantly below the 3.6% benchmark set by the Health Policy Commission. Hospital inpatient costs increased less than 1% from the previous year and there were notable improvements in performance on many quality measures. MassHealth expenditures decreased last year after two years of above-benchmark growth, and preferred provider organization (PPO) members under alternative payment methodologies (APMs) also increased.

While CHIA’s report did find that hospital outpatient spending growth exceeded the benchmark for a second year, the increase in this area was down from the year before. The report doesn’t provide further insight into what could be specifically driving the increased outpatient spending. A quick MHA analysis posits that the increase in outpatient costs could represent an overall positive change – such as procedures moving from inpatient to outpatient settings. MHA encourages a further “under the hood” look at the trends to ensure they are well understood.

MHA’s President & CEO Steve Walsh said of the report, “All of the improvements CHIA highlighted are directly threatened by Question 1 on this November’s ballot, which proposes mandated one-size-fits-all registered nurse staffing ratios. Research shows the ballot proposal will increase healthcare costs by more than $1 billion annually while creating barriers to access and forcing closures of services throughout the state.”

Secretary Sudders Announces Creation of Sepsis Consortium

Last Thursday, in recognition of World Sepsis Day, Health and Human Services Secretary Marylou Sudders marked World Sepsis Day by announcing the creation of the Massachusetts Sepsis Consortium, a public-private partnership of more than 25 organizations, including MHA, to collectively address the public health threat sepsis presents.

Sepsis takes a life every two minutes in the U.S. and affects more than 40,000 Massachusetts residents each year – yet, its threat is not commonly known to the public. Sepsis is the body’s overwhelming response to serious infection, which can lead to tissue damage, organ failure and death. It is the leading cause of death in hospitals and the costliest condition to treat in the United States.

“The goal of the Massachusetts Sepsis Consortium is to save lives by increasing awareness of the signs and symptoms of sepsis,” said Secretary Sudders. “This includes the need for people to seek immediate care and for providers to promptly diagnose and treat sepsis before it’s too late … The Consortium’s multi-sector collaborative approach will serve as a model for addressing health challenges that require a shared commitment from public and private actors.”

Two members of the Massachusetts Sepsis Consortium spoke regarding the profound effect of sepsis on patients and families.  Doreen Bettencourt, BSN, a nurse who is a sepsis survivor, serves as a patient advocate and a staff resource in hospitals.  Tina Edwards, LICSW,a social worker, has joined the National Family Council on Sepsis, along with her sisters to raise public awareness about the importance of recognizing and treating sepsis early in honor of their mother.

 “Massachusetts hospitals are on the front lines of dealing with sepsis, and are committed to improving early diagnosis and treatment of this life-threatening condition, particularly when patients come in to an Emergency Department,” said MHA’s Vice President of Clinical Affairs Pat Noga, RN, PhD, FAAN. “MHA looks forward to working with its member hospitals, fellow sepsis consortium partners and patients and families to increase public awareness and address this vital public health concern.”

The Massachusetts Sepsis Consortium will: identify and disseminate strategies to advance the prompt diagnosis and treatment of sepsis in all healthcare settings; increase awareness about sepsis prevention, symptoms, and when to seek medical care; and recommend an approach for tracking trends in sepsis morbidity and mortality statewide. The Betsy Lehman Center for Patient Safety will coordinate the effort.

Consortium members include experts from multiple state agencies, healthcare associations, patients, insurers, and advocates, as well as Senators Jason Lewis (D-Winchester) and Mark Montigny (D-New Bedford), and Representative Kate Hogan (D-Stow). The Consortium has formed two task forces: one to support implementation of sepsis screening and treatment protocols in emergency rooms, and a second to plan a robust sepsis awareness campaign.

Visit here for more information and to see a complete list of Massachusetts Sepsis Consortium members.  And visit here for a summary of last Thursday's event and some powerful video clips from it.

Today is Falls Prevention Day at the State House

The Massachusetts Falls Prevention Coalition, of which MHA is a member, is holding the 12th Annual Falls Prevention Awareness Day event at the State House today, Monday, September 17. If you are in Boston, stop by. The event is co-sponsored by the American Physical Therapy Association of Massachusetts and Benchmark Senior Living. In Massachusetts, in one year, more than one in four community-dwelling older adults will fall and of those who fall, over one in three will be injured. However, most falls are preventable through some very simple lifestyle changes. Learn about them at this event. For more information about the MA Falls Prevention Coalition, click here.


The Schwartz Center for Compassionate Healthcare has named Matt Herndon as its new CEO. Most recently, Herndon worked as Chief Legal Officer & V.P. of Government Affairs at Boston Medical Center’s HealthNet Plan. The CEO post replaces the position formerly known as Executive Director.

Opioids & Substance Use Disorders: Connecting Patients to the Right Care at the Right Time

Friday, October 26; 8:30 a.m. - 3 p.m.
MHA Conference Center, Burlington, Mass.

As the battle against opioid use disorder continues, the behavioral healthcare system and other medical professionals are mobilizing to provide the most effective care for patients. To ensure patients are triaged with careful planning and post-treatment plans, we will focus on care across the continuum. We’ll look at current best practices to get patients into treatment, featuring experts from hospital, post-acute, community, and criminal justice perspectives. In addition to the patient care sessions, we will also provide a comprehensive update of recently passed legislation affecting treatment regarding opioids and substance use disorders.  This is a timely, don’t-miss conference. Learn more by clicking here.

John LoDico, Editor