TESTIMONY
HOUSE of REPRESENTATIVES
FISCAL YEAR 2005 BUDGET TASK FORCE ON HOSPITALS
March 15, 2004

My name is Julie Pinkham, executive director of the Massachusetts Nurses Association. On behalf of the 22,000 registered nurses and health care professionals of the MNA, I commend you for holding this most important hearing. Candidly, something of its sort is long overdue.

The MNA represents registered nurses on the front-line of today’s health care delivery system in all settings, with the largest portion of our membership working in our acute care hospitals. In fact, MNA has members who are front-line nurses working in every hospital in the state, and through our collective bargaining program, we represent nurses working in 60% of the state’s acute care hospitals.

My remarks today depict the frustration that front-line registered nurses feel each and every day they arrive in a hospital floor or unit. From the perspective of nurses who work on the front-lines and spend more time with patients and their families than any other provider group, the Massachusetts health care and hospital system needs an overhaul and real reform: it deprives access to those who need services and delivers inadequate to unsafe care to those who manage to obtain access. While structured with the goal of being economically efficient, our health care system is one of the most costly in the nation. Unless dramatic changes are made, it is a system with no prospect of emerging from its current crisis state.

You have and will no doubt hear from a parade of MHA and local hospital executives who will bemoan their financial condition, decry the Governor’s proposed cuts, trumpet their slim profit margins, and seek increased Medicaid and uncompensated care pool funds. I respect their position and, as we have in the past, support their efforts to secure additional funding.

To that end, if the ultimate goal is to put paint on a badly rusted car, let me get the obvious out of the way and urge you to reject the Governor’s proposals, as they are indeed draconian and counterproductive, and let me join those who urge you to prop up the always fragile free care pool for another year.

Registered nurses have long stood on the front-lines of health care and fought for health care policies and initiatives that emphasized prevention, education, quality patient care and access to health coverage for all. We believe that the Romney health care budget fails in each one of these areas. We have long stood on the front-lines of health care and fought for health care policies that exemplified the adage that “an ounce of prevention was worth a pound of cure.” However, if we are to pick a phrase to describe the health care budget proposed by Governor Romney, it would again this year be “penny-wise, but pound-foolish.”

These cuts are shortsighted, misguided and devastating. Not only are these cuts harmful in their impact on the citizens of the Commonwealth, they are economically wasteful, ultimately resulting in patients receiving more costly care in already overcrowded emergency rooms. While the Governor has called for an equal sharing of the burden of cuts to the budget, his approach to the health care sector shows a lack of understanding of the unequal burden borne by health care providers.

Put simply, the Governor has broken his historic campaign promise to not cut core services. Health care is not only a core service, it is a safety net, a matter of life and death for vulnerable children, seniors and our entire citizenry.

But if you want more than a coat of paint on a rusted car, or more than a band aid approach, if you are truly looking to solve the problems imbedded in this crisis, if you truly want to fix what is wrong with the hospital industry, we urge you to look deeper into this issue and to examine the assumptions underlying the system we now have in place.

• First, we must ask ourselves if the free market system of open competition, or warfare between the hospitals supported by the industry is working for anyone. We believe the current system which former Senator Ed Burke characterized when deregulation legislation was passed as “putting all the scorpions in a bottle,” is not working. Look at the record, 30 hospital closures in the last decade, very few of which were in any way based on the needs of the communities served by those hospitals, but simply justified by the needs of the biggest hospitals/networks in that market. Ask the citizens of Waltham how well served they have been by the market, where CareGroup stripped them of their viability, transferred massive amounts of debt to their books, and when the community scrambled to give the facility life, Partners stole their physician base ultimately causing the hospitals failure in spite of the community’s efforts. Think about it, you had to pass a law to tell one hospital they couldn’t knowingly send an uninsured patient to another hospital without letting them know they were uninsured.
  
• Next, we must ask ourselves if hospitals are as bad off as they claim to be each and every year. The fact is, you have no way of truly knowing the true financial condition of these facilities. The Boston Globe recently reported that Partners will make $28 million this year, Boston Medical Center will make $5.3 million, and North Shore Medical Center is on track to make $6.5 million this year. Lahey, MetroWest Medical Center, Jordan and Morton Hospital all have hospital expansion plans underway in excess of $150 million. They are not concerned about meeting the costs associated with these expansions, finding the nurses to staff the beds, and their lenders must feel comfortable they can meet the debt service associated with any loan.
  
  Accordingly, as we look back over the transformation of the hospital industry since deregulation, we find the formation of large networks designed to leverage insurers and close weaker hospitals. The vast administrative and large bureaucracy of networks such as Partners and CareGroup have created a thick layer of costs to our health care system with none of these dollars providing patient care and who pays? Nurses will tell you who is truly paying, it’s the patient. As all these millions of dollars are being diverted to lawyers and business planners and executive offices, patients are pushing a call button and waiting, and waiting and waiting, sometimes to the point of death for care that is not being provided. We have nurses at UMass Memorial Health Care that have the worst staffing ratios in the state and can’t get a blanket for a patient, or a bed that works, yet that system paid over $2 million in severance to two failed CEOs, one of whom left in disgrace for lying on his resume.
  
  So what’s everybody afraid of? That someone needing care can’t or won’t get it or that another hospital will close? Well the current system is designed for the latter to occur regardless of any reimbursement improvements the legislature may make. The system is designed to compete; whatever you do may elevate the success or hasten the demise, but it won’t change the goal of hospitals to gain market share which will ultimately cause those who cannot compete to fail. The push for cardiac services is not based on public health assessment, it is based on creating a profitable service line. There is no incentive (other than that created for Cambridge Health Alliance and Boston Medical Center) for services to entice non –insured populations for primary care services. There isn’t a big push to open up AIDs beds or mental health beds…. even if there is a public health need. Why, because it’s not profitable. If our fears were truly based on the first concern – that someone needing care won’t get it – we wouldn’t be embracing free market as our health access policy.
  
• We must ask ourselves how patients are actually doing under the current system. Isn’t that the point, to make sure people are getting the care they need when they need it, and that when they receive care, it is working. But the hospitals in Massachusetts and the MHA have resisted accountability at every step, particularly when it comes to the quality and safety of the care they provide. What are the staffing levels on the floors of our hospitals, what are the outcomes for the patients? What is the infection rate, the rate of patient falls hospital by hospital, the rate of medication errors, complications, readmissions, all those indicators that tell us whether people entering a hospital are getting proper care. We have a bill referred to as the “patient report card” to track these items that the industry has testified against in the past.
  
  When shocking data is provided, like the 76% increase in injuries and complaints by patients reported recently by DPH, the industry claims there is no problem. They do the same when a recent independent survey of nurses in the state (70% of whom aren’t MNA members) reveal that one in two nurses reports increases in injuries to patients, harm to patients, readmission of patients, when 65% report increases in medication errors and nearly one in three report patient deaths due to unsafe RN-to-patient ratios. At every turn, they downplay or ignore data that shows quality and safety problems. They oppose any attempt to require them to establish and live by standards of care that can be measured and monitored. This is evidenced most recently by their vehement and, we believe, dishonest campaign to discredit H. 1282, legislation that would simply ask them to establish a safe minimum standard of care for all patients in our hospitals.

We come here today to get real answers to real questions that effect real people – our family, our friends, our neighbors. We hope you will look deeper into this issue and listen to those on the front-lines who really know what is happening to citizens of the Commonwealth. That being expressed here is what we propose you might consider doing to address these issues.

The MNA proposes the following INITIATIVES:

• Expand upon existing data and reporting requirements to ensure a true, publicly accessible, financial assessment of the industry by including all of its relationships whether they be to a parent organization or subsidiary corporation.
  
• In the FY 02 budget the Legislature passed Outside Section 28 which directed the division of health care finance and policy to collect and analyze data in order to better protect the public’s interest in monitoring the financial conditions of acute hospitals. This helps to ensure accountability of our health care dollars and assist in improving patient care by allowing us to utilize this data to improve services. This data collection and analysis includes gross and net patient service revenues, sources of hospital revenue, inpatient and outpatient trends, hospital volume and length of stay. Understand, until this passed, there was nothing. In fact, at a later Health Care committee hearing, this on hospital closures, this section was heralded as a great tool. We all need the ability to do more with this tool, collect more data and information in a more-timely manner. The picture we have must be accurate, not a reflection of the accounting shell game provided under the existing disclosure requirements.

• Develop and act upon hospital stabilization legislation that calls for a comprehensive review of the current system and the needs for hospital services, provides a mechanism to protect existing hospitals, and creates a receivership option for severely trouble institutions.
  
• Regardless of the Healthcare financing system established, we must ensure the quality and safety of patients’ care for in our hospitals, we once again call upon the legislature to pass H. 1282, Quality Patient Care, Safe RN Staffing legislation that will finally guarantee all patients in the Commonwealth a safe minimum standard of care.
  
• And finally, the ultimate solution to providing accessible, efficient health care ultimately lies in doing away with the current system altogether, and moving to a single-payer system of health care delivery, as provided for under S. 686 through the creation of a Massachusetts Health Care Trust. While we recognize the political reality of this proposal, health care reform must happen. We cannot sit by the wayside trying to cut and slash our way to health care reform. We cannot trumpet Medicaid cuts just to see the person walk in our emergency room with something that could have been handled with preventative care. We cannot eliminate MassHealth basic then not expect the demand on the uncompensated care pool to rise. We cannot give hundreds of millions of dollars in taxpayer money and not expect accountability.

One must first look at the historical trends that have brought us to the current situation. I know the task before you is difficult, the choices hard. As someone who has spent more than 14 years both as an oncology and a critical care nurse on the front-line of our health care delivery system, and as someone who has the honor to be here today representing thousands of registered nurses -- I implore upon you to reform and create a meaningful system of accountability for the Massachusetts tax-payers health care dollars.