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Berkshire Health Systems Has 'Legitimate Concerns' With Ballot Question
By Andy McKeever, iBerkshires Staff
03:58AM / Wednesday, October 03, 2018
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Berkshire Medical Center says not all the staff are on board with Question 1, providing a group photo to prove it.
PITTSFIELD, Mass. — Berkshire Medical Center officials estimate that it'll cost the hospital $22.8 million if Question 1 is passed.
 
Voters will decide in November whether to legally mandate specific ratios of registered nurses to patients. Berkshire Health Systems is opposing the question, fearing the costs will prove to be detrimental to the services it provides.
 
"It requires us to hire between 120 and 130 registered nurses. Do the math, it is about $20 million for Berkshire Medical Center. It is a lot of money," President and CEO David Phelps said in an interview on Friday.
 
Phelps said Berkshire Health Systems would have to hire 125 new nurses at BMC, adding $22.8 million to the annual operating budget and Fairview Hospital in Great Barrington would be looking at $1.4 million. Phelps fears for the long-term financial implications it could have on not only the hospital but other health providers in the area. He said there are "unintended consequences" associated with the question that could ultimately limit the services patients can access.
 
"You can't determine when people are coming. If you can't meet the needs of the patient when they present, you have limited choices — either pay huge fines or ship the patient somewhere else if you can find somewhere that is compliant," Phelps said.
 
"This is not anti-union or anti-nurse, we have legitimate concerns about what this means. I don't think it was their intent to introduce a bill that raises all of these issues but they have, perhaps unintended consequences."
 
Chief of Staff Daniel Doyle said currently the hospital works with "care teams" consisting of staff from different disciplines — doctors, registered and licensed practical nurses, aides, therapists, and more — to care for patients. The hospital tries to match up which specialties are needed for a patient census. 
 
"That requires a great deal of flexibility. That is something that can change not just shift by shift but even in a single shift if some patients leave and new patients come in," Doyle said.
 
Particularly, there is concern over language in the question that reads 'at all times' because that means if a nurse calls out sick or there is an unexpected influx of patients, the hospital could quickly be out of compliance, which carries a $25,000 civil penalty.
 
Doyle said nurses currently have lunches covered by others and simply increasing staffing to cover that with the current ratios would require hiring 25 more nurses. It requires the same ratios during the evenings when most patients are sleeping, adding more registered nurses.
 
"If you don't adhere the ratios, you are subject to a $25,000 fine per episode. The 'at all times' doesn't exist in the California mandate, the financial penalty does not exist in the California mandate. It is going to exist in Massachusetts if this passes," Doyle said.
 
A 1999 ballot measure in California instituted nurse-patient ratios but left the actual numbers up to the recommendations of the state's Department of Public Health, which put them into effect in 2004. Massachusetts' Question 1 details the ratio of patients to registered nurses and sets the penalty for noncompliance.
 
Doyle described a hypothetical situation, saying if the hospital falls out of compliance four times a week in any area of the campus, it would rack up $5 million in fines in one year. 
 
"We could cut all of the administrator salaries way down and we're not going to find $5 million, never mind the cost to hire these RNs," Doyle said.
 
Phelps said the hospital would have to not only hire up to make sure the ratios are hit but add even more just to avoid being levied those fines.
 
"This significantly changes 24-hour coverage so it has more nurses. It creates this 'at all times' provision so given the financial penalties you would probably hire more nurses to cover in the event of something happening. And to cover breaks and lunches, it is 25," Phelps said.
 
Phelps said he doesn't know where he would be able to find that many nurses is such a quick time — the law if passed goes in effect on Jan. 2, 2019. 
 
"We are always supportive of Berkshire Community College where we get most of our nurses," Phelps said. "They put out 35-40 a year, maybe, that would barely keep up with attrition. So we don't know where we'd come up with 125 nurses. More importantly, the effective date is shortly after it is passed. It is not like we have a year or two to comply."
 
Berkshire Medical Center won't be the only hospital in the state that will be scrambling for nurses. Doyle is concerned there would essentially be a bidding war for nurses across the state.
 
"This is bigger than what the union would like you to believe, that this is just wealthy hospital who doesn't care about their nurses or patient safety. That is just not so," Phelps said.
 
The potential impact of a nursing shortage also threatens the way health care has been operating, he said. Phelps said insurers and government reimbursements have been focused on keeping people healthy and out of the hospital, and a lot of that depends on ancillary services, such as the Brien Center and other health-care providers. If Question 1 is passed, hospital officials say the demand for nurses would further concentrate resources to the hospital, cutting back what is done outside of it. 
 
"Our resources should be out there, trying to keep people from getting sick," Doyle said. 
 
The Massachusetts Nurses Association, the union representing about a quarter of the state's registered nurses, has been particularly driven in advocating for the passage. The union nurses at Berkshire Medical Center recently went on strike — and were hours away from a second strike — as the safe staffing issue presented the major linchpin in negotiations. 
 
The union says the intent is to ensure nurses aren't being overworked and patients are receiving proper care. The union says it is an issue of "safe staffing." Hospital officials say they will support investing in patient care, but this ballot question doesn't do that.
 
Doyle worked in the intensive care unit for years and when mandated ratios were implemented there, the care that patients received didn't change. He said Massachusetts ranks higher in health outcomes than California, which has had mandated safe staffing levels for 14 years.
 
"The idea of having safe staffing and safe patient care is something we all value highly. I don't see this as contributing to that at all," Doyle said. "It really takes away a lot of flexibility. It doesn't promote safe patient care."
 
Those in favor of the question will quickly point to the amount of revenue Berkshire Health Systems takes in, but Phelps said there is no certainty those numbers will stay consistent. He said much of the recent success came from the stock market, and not so much from the services provided. He said the hospital pays some $40 million a year in capital costs for things as equipment replacement. And each year costs continue to rise while reimbursements haven't been keeping pace.
 
"It is true we've performed well financially. But it is also true when you look ahead five or six years, it is hard to imagine we'd perform as well as we do today. That has implications for anyone who depends on us," Phelps said.
 
As costs increase, Phelps said managing the health-care system is going to be much more difficult. The emergency room, for example, requires a constant and orderly flow of patients. After being treated, the patient gets moved to another section of the hospital. But if that desired department is out of compliance with the ratio, then the hospital is in a position to make the patient wait, find somewhere else to send the patient, or take the fine. Phelps said in no way would anybody be turned away but it does add significant hitches to management.
 
A brief analysis commissioned by the MNA from Judith Shindul-Rothschild, an associate professor at the William F. Connell School of Nursing, Boston College, puts the cost to implement the law at $35 million ot $46 million. Using California as a benchmark, she pegs it as closer to $23 million. Hospitals already profitable are likely to remain so.
 
The Massachusetts Health Policy Commission is also expected to release an independent report this week on the statewide financial implications.
 
A summary of the ballot question aspects available at the secretary of state's website. 
 
iBerkshires is presenting the local chapter of the Massachusetts Nurses Association's view on the issue in another story. 
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