News & Events

New Study Finds Hospital Executives Grossly Exaggerating Cost of Question 1

(Study available at

Today, members of the Committee to Ensure Safe Patient Care shared a new study by Judith Shindul-Rothschild, PhD, RN, a nursing economist at Boston College and a leading researcher on RN staffing and patient care quality. The study outlines the costs associated with implementing safe patient limits in Massachusetts acute care hospitals as called for under Question 1. The study shows a total cost for Massachusetts acute care hospitals to implement the law of under $47 million, which is a fraction of than the $1.3 billion figure posited by the opponents of Question 1. 

The study finds hospital executives are grossly exaggerating the costs to implement the patient safety initiative, and that hospitals can easily afford to ensure safer staffing with limits on nurse’s patient assignments.

The study utilizes real-time data from the Massachusetts Health and Hospital Association (MHA) and matching data comparing staffing levels and costs with the California hospital industry. The $47 million cost estimate was derived by calculating a proportion of RNs to total Massachusetts hospital personnel equivalent to California where RN-to-patient limits have been in effect since January 1, 2004. The proportion of RN full-time equivalents (FTEs) to total hospital personnel in California is 30 percent, as compared to the average in Massachusetts of 27 percent. The total annual estimated cost of RNs on medical-surgical, stepdown, behavioral health and emergency departments was subtracted from this sum. (See Figures 1 & 3 in the accompanying report.) Based on this formula, 37 Massachusetts hospitals (55 percent) would have no increase in costs. 

“The majority of Massachusetts hospitals could easily meet the requirements of the law simply by shifting approximately 3 percent of the proportion of their budget currently allocated to non-direct care managers and hospital administrators, to RNs and hospital unit staff who provide direct patient care as was done in California hospitals after the enactment of their law,” Shindul-Rothschild explained. “At the end of the day, we estimate that after implementing the limits of Question 1 our state’s hospitals would still retain a mean profit margin of $15 million a year.”  

The study evaluated current staffing levels for emergency departments, medical surgical floors, step down units and behavioral health units, for 67 acute care hospitals, which comprise most of the beds covered by the law. It did not examine intensive care units, as there is a law already in place regulating patient limits for those units. It also did not examine maternity units or operating rooms, as those units are already staffed at or near the level called for by the initiative.

“This study makes clear that ensuring our hospital industry fulfills its mission of providing safe, high quality care for our patients is simply a matter of where they choose to invest their existing vast financial resources: Is it at the patient’s bedside to ensure when a call button is pushed the nurse is there to respond when it matters most; or is it in corporate office suites where the priority is on pushing computer keys to input numbers on a financial spreadsheet,” said Donna Kelly-Williams, RN, co-chair of the Committee to Ensure Safe Patient Care and President of the Massachusetts Nurses Association.  

The new cost study is being released following a series of state reports and news stories about the multimillion-dollar profit margins for Massachusetts hospitals and hospital networks. These hospital corporations are behind the deceptive no campaign claim that they can’t afford to meet the safe patient care limits called for by nurses with Question 1. But at the same time, news outlets are reporting enormous compensation packages for hospital CEOs, including raises for some of between 50 to 80 percent; and profits of more than $1 billion in 2017 for the Massachusetts hospital industry.  

Shindul-Rothschild added that this analysis doesn’t include the cost savings that research has shown can be realized by hospitals when they have safer patient limits as called for in Question 1.  

“Multiple studies in the nation’s leading scientific journals have found strong evidence of a causal relationship between the patient outcomes and the adequacy of registered nurse staffing. Based on these research findings, limits on the number of patients cared for by registered nurses will have the greatest impact in improving the quality of nursing care and patient outcomes in hospitals across the Commonwealth,” she states in her study.

Shindul-Rothschild, again using the MHA’s own data, has published five peer-reviewed studies in the last four years of Massachusetts hospitals that demonstrate the importance of safe patient limits on the care of patients in our state’s hospitals.

“Throughout my career, and in testimony over several decades about health care financing in the Commonwealth, I have emphasized that to sustain quality and access to care in Massachusetts hospitals it is vital that we assure there are adequate numbers of registered nurses at the bedside,” Shindul-Rothschild concluded. “Given the findings of my research, I believe more strongly now, than I did decades ago, that there must be limits to the numbers of patients cared for by registered nurses