Ratios Would Cost $949 Million and Raise Premiums, plus more...

HPC Report: Question 1 Costly, Harms Access, Won’t Improve Care

The state’s Health Policy Commission released its independent, unbiased study of how mandated nurse-to patient staffing ratios contained in ballot Question 1 would affect the Massachusetts healthcare system, and found that Question 1 would cost the state up to $949 million annually, would most likely result in “no systematic improvement in patient outcomes,” and would adversely affect community hospitals serving a high proportion of MassHealth and Medicare patients.

The HPC’s $949 million upper cost estimate does not include the cost associated with emergency departments (which require four different ratios under Question 1), or costs relating to outpatient departments, observation units, all non-acute hospitals, as well as state agency implementation costs and penalties for non-compliance.

The $949 million estimate is similar to the figure that Mass Insight and BW Research Partnership arrived at through their research, but is $900 million more than the MNA’s much-derided estimate of $47 million annually.

“This is an absolutely terrifying day for healthcare in our state,” said Dan Cence, spokesperson for the Coalition to Protect Patient Safety. “The Health Policy Commission’s analysis confirms that the negative consequences are too great and the costs are too high for rigid, government-mandated nurse staffing ratios in the commonwealth. This puts the cost question to bed.”

The HPC’s research was conducted by the commission’s Research Director Dr. David Auerbach and by University of California San Francisco Professor Dr. Joanne Spetz.

The researchers found that the only other state with mandated ratios – California – imposed a markedly “less strict” mandate on its hospitals than is proposed in Massachusetts. California had five years to implement the law (as opposed to 37 days in Massachusetts), allows a 1:5 ratio on Med/Surg floors (1:4 in Mass.), and allows waivers for dozens of rural hospitals (no waivers are permitted under Question 1). Also there are no non-compliance penalties in California, but in Massachusetts hospitals would have to pay up to $25,000 per day, per incident for violating the rigid and arbitrary ratios.

But the main – and most important – difference between California and Massachusetts is that Bay State hospitals deliver better care to patients and that in California “there was no systematic improvement in patient outcomes post-implementation of ratios,” according to the HPC.

The HPC concluded, “If the proposed initiative becomes law, the increased costs to hospitals may result in impacts such as:
Reductions in hospital margins or assets
Reduced capital investments
Closure of unprofitable (and/or other) service lines
Reductions in non-health care workforce staffing levels.
“These costs could also lead to higher commercial prices for hospital care, potentially leading to higher premiums.”

“The HPC’s findings reaffirm multiple warnings about the true costs Question 1 would force on patients, their families, insurers and healthcare providers,” said Steve Walsh, MHA president & CEO. “In particular, it asserts the increased costs for high public-payer hospitals – serving some of the commonwealth’s most challenged communities – would be most affected, with the possibility of devastating effects to patient access to care. With regard to emergency departments, the HPC also finds the potential for ‘significant impacts’ on access to emergency care, wait times, patient flow, emergency room boarding, and ambulance diversion. Though the supporters of Question 1 have dismissed these concerns as ‘scare tactics,’ the HPC recognizes that these are very real threats to patients in our communities. Every hospital in Massachusetts opposes Question 1. That’s why we are part of the Coalition to Protect Patient Safety. This coalition includes more than 100 healthcare organizations and is striving to put daylight on the troubling consequences this ballot question poses to patients and communities throughout the state. Today’s report by the HPC further reinforces the harm Question 1 poses and provides additional evidence as to why voters should say ‘No’ to Question 1 on November 6.”

Your Health Premiums Will Increase

The group representing health insurers in Massachusetts said following release of the HPC report, that if Question 1 passes and its $900-plus million cost is foisted on the healthcare system, consumers will likely pay more in premiums. The Massachusetts Association of Health Plans (MAHP) said on October 4, “We appreciate the expert analysis conducted by the HPC. Their analysis found that Question 1’s provisions could raise health care costs by more than $900 million annually, with no measurable improvement in quality of care for patients. This increase in spending will likely result in increased premiums for employers and consumers, and based on these findings, will threaten our state’s ability to meet the health care cost growth benchmark. Based on the HPC’s analysis, MAHP opposes Question 1.”

Group After Group Outlines Destabilizing Effects of Mandated Ratios

In its report on the excessive costs that Question 1 would impose on the Massachusetts healthcare system, the Health Policy Commission (HPC) noted that “a majority of stakeholders identified proposed mandatory nurse staffing ratios as a top area of concern.”

The stakeholder comments came from pre-filed testimony that had been sent in recent weeks in preparation for HPC’s October 16-17 annual cost trend hearing. The HPC will address mandated nurse staffing ratios at that hearing and will include a panel discussion on the topic. The HPC annually sets a statewide target for total healthcare spending. That target is 3.1%, which many feel cannot be met with the imposition of nearly a $1 billion in new annual costs as a result of government-mandated staffing ratios.

More than two dozen hospital, insurers, or physician practices included in their testimony fervent pleas against ratios. Some examples follow:

Atrius Health said as hospitals would be forced to hire more nurses there would be “attendant increases in costs of care and difficulty for Atrius Health in recruiting nurses to support ambulatory and home-based care.”

Baystate Health decried Question 1’s “astronomical and unfunded price tag, no promise of improved care, lack of scientific data to support the proposed law’s arbitrary staffing levels, loss of bedside control for nursing staff, and a downstream of other unintended negative consequences.”

Cape Cod Health said its financial hit from Question 1 would drive its cost growth north of the state’s 3.1% cost growth benchmark. To meet that benchmark, “service lines which are already vulnerable, such as infectious disease, behavioral health, and obstetric clinics will be at risk of survival.”

Holyoke Medical Center envisions “closure of essential services” if the ballot question passes, and Mercy Medical Center/Providence Behavioral Health Hospital said the costs associated with Question 1 “will have a particularly destabilizing impact” on behavioral health.

Reliant Medical Group wrote that “the increasing labor market competition and escalating salaries for nurses could significantly hamper our efforts to manage total medical expense by engaging in comprehensive care management and population health activities.”

And Southcoast Health stated strongly that “Public healthcare policy must be made by trained, experienced healthcare professionals at the bedside and not initiated by special interest groups that garner enough signatures. If passed, the Nurse Staffing Ratio will create onerous and unnecessary operational challenges and ill-advised internal restructuring that will lead to a loss of critical healthcare services.”

Opioid Bill Sent to President

By a vote of 98 to 1, the U.S. Senate passed a large bill to fight the nation’s opioid crisis, and sent it to President Trump for his signature. The House had passed the measure the week before by a 393 to 8 vote.  Utah Sen. Mike Lee (R) was the only Senate opponent of the bill that combines numerous proposals and initiatives across many federal agencies.  For example, one measure calls for the U.S. Postal Service to screen packages shipped from overseas for the synthetic opioid fentanyl. Last Thursday in Massachusetts, U.S. Attorney Andrew Lelling announced a major drug raid in Lawrence that seized more than 10 kilograms of deadly fentanyl. “The amount of fentanyl we have seized today could kill half the state,” or approximately 3.4 million people, Lelling said.


Norm Deschene, the CEO of Wellforce, announced last week that he intends to retire at the end of 2018. Deschene led Lowell General Hospital as COO and CEO for 31 years before helping to create Wellforce and serving as its CEO since its 2014 inception. He served on the MHA Board of Trustees for a decade and was chair during the Board’s 2011-12 term.  His peers in Massachusetts healthcare consider Deschene to be a very forward-thinking, innovative leader, who had the foresight to see how recent transformational changes to healthcare payment and delivery systems would affect the institutions he ran and the patients they served.  Wellforce’s Board announced it would appoint an interim leader shortly and begin a national search for a new CEO.  His colleagues at MHA wish him a happy retirement.

2018 Throughput Conference: Current Best Practices & the Impact of Artificial Intelligence

To adapt to healthcare’s constant state of change, Massachusetts hospitals continue to work on thoughtful implementation of efficient patient flow, process improvements, and culture change. Adding to the mix are exciting developments in artificial intelligence to help with patient flow. At this year’s throughput conference we’ll hear from experts and local practitioners on the best practices and new strategies to provide the safest possible care in the most efficient way.  Topics include: Opioids & Substance Use Disorders: Emergency Department Throughput Strategies for Today’s Behavioral Health Challenges; Integrating Process Improvement, Project Management, and Change Training; Using Proactive Patient Progression to Drive Patient-Centered Care; How One System Handles Electronic Handoffs and Use of Queuing Theories in Scheduling; and Artificial Intelligence: New Frontiers in Efficient Patient Care. Click here to learn more about this conference that will be held on Friday, November 9 from 8 a.m. to 3 p.m. at MHA's Conference Center in Burlington, Mass. 

John LoDico, Editor