Mayflower Winter 2007 Volume 18 Issue 1 Governmental Affairs Maureen McLaughlin, BSN, RN, CPAN Mandated Staffing Ratios Rep Christine Canavan (D-Brockton) has informed legislative colleagues that she intends to re-file the House staffing bill (HB 4988), which if enacted would implement mandated staffing ratios. MASPAN remains opposed to this legislation. Statewide Health Insurance In April 2006, the Massachusetts legislature approved the Health Care Access and Affordability Act, aimed at ensuring that the majority of uninsured Massachusetts residents (estimated to be 150,000) have access to affordable health insurance within the next three years. This new law is the first of its kind in the country. The Health Care Access and Affordability Act: • Requires employers with eleven or more employees to either provide health insurance to their employees or pay $295 to the state • Requires individuals to purchase health insurance if a comprehensive plan is available at an affordable price or face tax penalties • Preserves Medicaid coverage and benefits and expands them to cover more low-income unemployed people, immigrants, people with disabilities, and children and families. This measure also restored adult dental care for Medicaid recipients. • Makes health insurance more affordable for uninsured working people through the Commonwealth Care Health Insurance Program, which will subsidize the cost of health insurance for those earning up to 300% of the poverty level. • Requires insurers to cover young people up to the age of 25 under their parents’ family plans • Increases Medicaid payments to providers, maintains funding for safety net hospitals, and requires providers to meet certain quality-improvement goals and reduce racial and ethnic health care disparities. • Establishes a new state agency called the Commonwealth Health Insurance Connector to define “affordable” health insurance for different income levels and to sell policies that are of value. (Hart, MA. (2006) Policy and politics. Massachusetts: Expanding access to care. American Journal of Nursing, 106, 10: 38-39.) There have been many meetings to develop strategies for a successful implementation of this new access to health insurance plan. Recent meetings have mainly focused on the group of uninsured people who are not eligible for the state-subsidized “Commonwealth Care” plan because they earn above 300% (see above) of the federal poverty level and for small employers not offering employer-sponsored insurance. Board members reported that they need to define specifically what it means to be “underinsured,” so coverage can be offered to address that situation. Bob Carey, the Connector's director of planning and development, said 200,000 people are uninsured and not eligible for the Commonwealth Care program. About 50 percent of those are between 19 to 44 years old, he said. The board needs to determine the “minimum credible coverage” criteria by the next meeting on Nov. 30 so officials can issue a Request for Responses (RFR) in December to commercial insurance carriers hoping to offer coverage programs to those who are uninsured. Some board members have expressed concerns that Massachusetts residents would encounter too many choices and struggle to make the best decisions. Currently, the Connector has entered into contract with four Medicaid Managed Care Organizations to provide "affordable" and subsidized insurance plans to uninsured individuals and families who earn up to 300 percent of the federal poverty level. The Connector Authority spent much of this fall developing guidelines for subsidized plans. According to the state mandate, on July 1, 2007 nearly all residents are required to carry health insurance that meets the state’s minimum coverage requirement or face financial penalties that would be exacted through tax returns. The Connector plans to have its Policy Subcommittee review and develop recommendations for the minimum creditable coverage criteria and the Connector plans to vote on the recommendations on Nov. 30. The Connector started enrolling all the individuals who earn below the 100 percent of the federal poverty level in full-state subsidized health insurance plans in October. As of Nov. 3, the latest figure disclosed, 3,569 individuals have enrolled in one of the four state-sponsored health insurance plans. About 20,000 residents are eligible for the first phase of the Commonwealth Care program. In January, the board plans to launch the second phase of the program and enroll individuals and families that earn between 100 to 300 percent of the federal poverty level in “affordable” and partly state-subsidized health plans. (State House News Service, Nov 9, 2006) Health Reform Law Education At a Blue Cross Blue Shield Foundation summit this week, experts in health care said they fear too many Massachusetts residents don't know enough about their roles and responsibilities under the dramatic health care law outlined above that will require individuals to have insurance by July 1, 2007. A major public outreach and education campaign is needed, but proponents of that campaign are worried because Gov. Romney just cut $2.7 million allocated for outreach. A foundation-commissioned poll found majority support for the law and its new program premiums for low-income residents. It also found fears that the law will trigger tax hikes on small business. In addition, there are concerns that residents who earn less that $50,000 will be opposed and/or financially challenged if they need to purchase health insurance. (State House News Service, Nov. 17, 2006) Massachusetts Health Care Costs A recent survey found that the healthcare costs in Massachusetts are among the highest in the nation and they are increasing at a faster rate than in most other states. Average healthcare costs for an individual employee, including medical, dental, dependent coverage and worker premium contribution, reached $9,428 in 2006 in Massachusetts. The only other states that contribute higher amounts are Alaska, New Hampshire, and Wisconsin. This figure indicates an increase of 8.2% over costs in 2005, also a faster rate of increase than most states. There are several factors that contribute to this cost. One factor is the large number of teaching hospitals in Boston, as well as the fact the Massachusetts has a high standard of healthcare. In addition, Massachusetts has been slow to adopt a “consumer-directed” health care plan, in which the consumer pays a large upfront deductible before benefits kick in. This type of plan has lower costs that the typical HMO plans, although these plans, by their design, require the member to contribute the first dollar of cost. Healthcare costs in Massachusetts have increased by at least 10% every year for the past 6 years. For 2007, the major health care insurers are predicting premium increases between 8 and 13%. (Boston Globe, Nov. 20, 2006, p. E1, E4) The City of Boston’s healthcare costs have nearly doubled in the past six years and now require the property tax of five families to pay the premium on one city employee’s family health plan. In order to bring some of the costs under control the city may begin shifting some of the healthcare policies and join the state’s healthcare plan. The estimated cost of health insurance for the city of Boston is $235 million, an increase of 92% since 2001. This year health insurance absorbed half of the city’s total budget increase. There are 28,600 subscribers to the city’s healthcare services, of which 45,000 are retirees. (Boston Globe, November 30, 2006, p. B 5.) Charge Nurses as Supervisors In a long awaited ruling, the National Labor Relations Board (NLRB) has ruled that charge nurses are supervisors under federal law and thus are exempt from union protections. This ruling defines a supervisor as a worker who gives assignments to other workers, is held responsible for the performance of those assignments, and exercises independent judgment. Hundreds of nurses could be affected by this new ruling, which would impact on their ability to bargain collectively. While supervisors can join unions, they are not legally protected from being fired or disciplined. (RN, Vol. 69, No. 11, p. 12) Pandemic Preparation The American Public Health Association (APHA) met in Boston in November. One of the hot topics was how to best address preparedness in the event of an influenza pandemic. APHA has recommended comprehensive national planning for this event. They feel that the U.S. Department of Health and Human Services (HHS) should be administratively responsible for this planning, not the Homeland Security Department. The coordination of agencies in the event of a pandemic was also discussed in their recommendations. The APHA urges revision of the National Response Plan to ensure that federal, state, and local officials are included in any planning. They also urged increased funding in order for public health care workers and health care institutions to be able to scale up their efforts to respond to a pandemic flu.(www.apha.org). For additional information related to the pandemic flu and other concerns, please see related articles at www.cdc.gov. Mayflower Fall 2006 Volume 17 Issue 4 Governmental Affairs Mandated Staffing Maureen McLaughlin, BSN, RN, CPAN Mandated staffing At the end of the legislative year in July, no action was taken on the issue of mandated staffing. The House had restructured the staffing bill and towards the end of June, sent the revised version to the Senate for debate and discussion. No action was taken on that revised bill, or on Senator Moore’s bill that addressed additional funding for nursing education. While we are relieved that no action was taken on a bill that MASPAN opposed, there remains the fact funding for nursing education was also not addressed. Again, MASPAN urges all of its members to contact their Senators and Representatives and discuss with them the challenges that are facing nurses today. A legislator armed with the facts can make an informed decision. The web page for the American Nurses Association has a section of staffing-related subjects. This section has a recent addition of issues related to nurse fatigue that is very informative and very relevant to our colleagues who are on-call. (www. nursingworld.org/staffing) Health Insurance Massachusetts legislators passed a landmark bill aimed at providing and requiring all residents of Massachusetts to have health insurance. Members of the board overseeing this process released the proposed rates for those residents who would be receiving their health insurance through the state, versus through their employer. The proposed monthly premiums would be $18 per person for those with an annual income of $9,804-$14,700. Co-payments will vary. Voluntary enrollment in these plans is expected to start January 1, 2007 but the program will become mandatory July 1, unless the individual is able to show that they cannot afford the insurance premium. The four major health insurers of Massachusetts plan to increase their premiums by more than 10% for 2007, affecting those residents in Massachusetts who obtain their health insurance through their employer. Some employers are expected to address this increase by either switching to health plans with higher deductibles or by increasing co-payments or other changes that will pass the increased cost of the insurance plan onto to the employees. (Boston Globe, September 10, 2006) At the national level, ranks of the uninsured grew by 1.3 million in 2005. According to the U.S. Census Bureau, the number of people in the U.S. without health insurance rose to 46.6 in 2005. In addition, the number of children without health insurance increased to 8.3 million. (Capital Update, ANA, August 2006) Healthcare Truth and Transparency Act H.R. 5688, the Healthcare Truth and Transparency Act, is a bill at the federal level that seeks to outlaw any act, speech, or practice conducted by a licensed health care provider who is not a medical doctor (MD), doctor of osteopathic medicine (DO), doctor of dental surgery (DDS), or doctor of dental medicine (DDM) that leads patients or the public to believe that the health care practitioner has the same or equivalent education, skills, or training as a physician or dentist. This legislation would bring these activities under the review of the Federal Trade Commission (FTC) and this organization would then have the ability to fine the health care practitioner up to $10,000 per violation. The American Nurses Association (ANA) has voiced opposition to this seemingly appropriate legislation, highlighting the following concerns: The bill fails to document any of the evidence that they cite as “ample” in justifying the need for this legislation. It also fails to recognize that if such a practice was performed by an advanced practice nurse, this inappropriate practice already would be governed by the state board of nursing.The typical Nurse Practice Act defines the authority and composition of the board of nursing; defines the boundaries of the scope of nursing practice; identifies types of licenses and titles; states the requirements for licensure; protects titles; and identifies the grounds for disciplinary action.In addition, the Healthcare Truth and Transparency Act is inconsistent in its approach to the issue of false representation of health care education and clinical training. It seeks to impose significant criminal penalties on a select group of licensed providers, while ignoring many others.The bill fails to recognize and address the actions and representations of MDs, DOs, DDSs, and DDMs that fall outside of their education, skills, and clinical training. The erroneous assumption that these providers should be exempt from the provisions of this bill does not serve today's patients and does not fulfill the intent of this legislation. (Capitol Update, ANA, August, 2006) Mayflower Summer 2006 Volume 17 Issue 3 Maureen McLaughlin, BSN, RN, CPAN House Bill 2663 The House passed an amendment on House Bill 2663, A Patient Safety Act. The original bill called for established nurse to patient ratios. The amendment contained language on nurse patient ratios but added additional language prohibiting mandatory overtime, increased nursing scholarships, and protection against the reduction of unlicensed assist personnel as the staffing ratios are implemented. This measure will move on to the Senate for consideration. No Endorsement MASPAN was asked by the sponsor of the mandated staffing ratios bill, the Massachusetts Nurses Association (MNA) to support this legislation. MASPAN did not and does not agree with mandated staffing ratios. While this amendment contains some safety language that is beneficial, such as protection against mandatory overtime, there are still concerns that remain concerning a law mandated staffing ratios. Lack of Research There is no research that clearly determines the number of patients that a nurse can safely care for. While there has been research that notes that the fewer the patients a nurse cares for the better the patient outcomes, there is no research that states what that number exactly is. There is a research project being conducted in California (www.calnoc.org) that is examining this, but it has not concluded. Some early findings have shown little reduction is patient falls or skin breakdown since the ratios have been implemented. Dispelling the Myths MASPAN remains opposed to mandated staffing ratios for the following reasons.
The ASPAN Standards delineate Phase I and Phase II nursing and make recommendations for the staffing in each area. Patients are described based on their acuity, such as awaiting discharge to home, parent present, etc. Mandated ratios do not address nursing care in either Preadmission, Phase II or Phase III (soon to be described as extended observation). All PACU areas are described as needing one nurse to two patients, taking no consideration of the actual nursing need required for those patients.
Research The reality is that the research that is cited as necessitating mandated ratios does not exist.
Change in patient’s acuity Case scenario: nurse A is admitting a fresh post-op who suddenly requires an emergency reintubation and vasopressor support. Ordinarily, her other patient would be cared for by nurse B, who has two patients on routine vital signs awaiting transfer to the inpatient unit. However, this would mean that nurse B would be caring for three patients at that time and that is in violation of the mandated ratios. Mandated staffing ratios would prevent nursing assignments based on patient acuity and nursing competence.
Overflow At the present time, many PACUs are caring for medical surgical patients who are unable to be transferred to the inpatient areas due to lack of available beds. However, when they remain in the PACU, they will require a one nurse to two patient ratio, as the bed is LICENSED as a PACU bed. The mandated ratio does not address overflow patients or ER holds. It only describes staffing based on how the bed is licensed in the state.
All Sides Need to be Heard There are many additional reasons to cite in opposition to a law that mandates ratios. I urge you to review the literature, consider the reasons cited above, and if you are in agreement with MASPAN, please contact your state Senator. Our legislators need to hear from all the nurses in Massachusetts, not just the ones who are members of collective bargaining units. Governmental Affairs Maureen F. McLaughlin, BSN, RN, CPAN Mayflower Spring 2006 Volume 17 Issue 2 Health Insurance The legislative session came to an end in December, 2005, still discussing the implementation of health care coverage for all Massachusetts residents. The debate will resume in January after the holiday break. Mandated Staffing Ratios The debate over mandated staffing ratios remains in committee and no final decision was made in the legislative 2005 session. It is expected that discussions on this matter will resume in 2006. Medicare Drug Plan Enrollment in Medicare’s new drug plan, Part D, began in the middle of November amidst much confusion. The federal drug benefit plan that takes effect in January in the most significant change to the Medicare system since it was created in 1965. Nationwide, about 40 million Americans are eligible to enroll and an estimated 30 million will take advantage of this plan. The estimated savings to seniors in the reduction of prescription drug cost is expected to be, on average, $792 per year. The challenge in the drug plan is deciding which plan best meets the need of the subscriber. One local editorial article listed a total of 59 options to enroll in and no clear indication of which plan would best benefit the subscriber. To add to the confusion, seventeen companies are offering stand-alone drug plans, often with multiple options. The deadline for enrollment is May 15, with the potential for a penalty if someone decides to enroll after that date. As the drug plan began to take effect in January, some seniors who had enrolled were unable to have their prescriptions filled, because some pharmacists could not confirm their new insurance coverage. In early January, Massachusetts state health officials acted to ensure that three vulnerable groups would receive prescription coverage immediately: low-income seniors, disabled people on Medicare, and those already receiving benefits under the state’s subsidy program. Health officials ordered pharmacists to fill prescriptions and in cases of confusion as to which drug plan is in effect, the state can be billed for the cost of the medication. The estimated cost to the state is between $1.5 and $2 million per day. The state will then try to collect the money from individual insurance companies that provide Medicare coverage. (Boston Globe, January 10, 2006) Federal Budget The combined cost of both the war in Iraq and the Hurricane relief efforts have challenged the federal government as they try to create a budget for 2006. The federal deficit is now estimated to be at $340 billion. Both sides of Congress struggled with budgets cuts and appropriations, as costs related to both the war in Iraq and Gulf relief efforts are steadily climbing. Hurricane Relief U.S. Senate Appropriations Chairman Cochran (R-MS) announced on Dec. 18, 2005 that he had secured an agreement for legislation that would provide immediate assistance to hurricane recovery efforts. The amount appropriated during negotiations is an estimated $32 billion for hurricane disaster assistance. The White House had initially requested $17 billion in aid for hurricane recovery efforts. Included in the $32 billion is $24 billion from previously appropriated FEMA spending. The additional $8 billion was created from budget cuts to discretionary spending. www.appropriations.senate.gov. Defense Spending The Senate and House of Representatives members of the Committee on Appropriations have approved a total of $453.28 billion in defense spending. Included in this amount is $50 billion for operations related to the Global War on Terror. This spending provides $50 billion for operations in Iraq or Afghanistan (Title IX) and it also fully funds military pay, benefits, and medical programs. Included in this appropriations bill (dated Dec 18, 2005) is a provision authorizing oil and gas exploration in the Arctic Coastal Plain. For the entire list of dollar allocation, please see: www.appropriations.senate.gov. Title VIII funding Funding levels for much of the health care budgets faced reductions as Congress attempted to come to an agreement on the budget late in December. Funding for Title VIII suffered a 0.6% cut, ending with an appropriation amount of $149, 679 million, down from the 2005 amount of $150,674 million. (ENA Washington Update, Dec., 2005) http://www.ena. org/government/washington/ Avian Flu As per the above report, $3.8 billion was allocated for the Department of Health and Human Services (HHS) to address the potential pandemic influenza. $2.75 billion is slotted for vaccines, anti-virals, and any other countermeasures that HHS determines are necessary to protect the health of Americans. An additional $350 million was directed to aid State and local public health departments plan and exercise their roles during a pandemic. $150 million is provided for international and domestic surveillance. www.appropriations.senate.gov. The Department of Health and Human Services (HHS) issued a recommendation in the event of a pandemic related to H5N1, the avian influenza. While there is still no vaccine available, HHS issued a checklist for citizens to use in the event of a pandemic: remain home and have a generous supply of: ready to eat foods, bottled water, cleaning supplies, over-the-counter medications such as Tylenol, cough and cold remedies, and fluids with electrolytes; teach children good hand washing skills; and discuss emergency action plans with family members. For more details, go to www.pandemic.gov. Patriot Act President Bush signed a bill that renews the Patriot Act for a few weeks into 2006, until Congress reconvenes and resumes debate over the antiterrorism law. The extension of the Patriot Act is set to expire in February, 2006. The extension that President Bush signed allows the FBI to continue to investigate terrorism cases using roving wiretaps, etc. and in some of these cases, without a court order. (Washington Post, Dec. 31, p.A2) Mayflower Winter 2006 Volume 17 Issue 1 Governmental Affairs Maureen F. McLaughlin, BSN, RN, CPAN Health Insurance The Massachusetts legislature has begun to tackle the subject of health insurance for the uninsured. Approximately 500,000 residents in Massachusetts lack health insurance. Many of the uninsured are employed full-time and are not offered insurance from their employer. For some who have the option of employer subsidized health insurance, the cost is too expensive. The percent of people living in America without health insurance is estimated to be 15.7%. In Massachusetts the percent is 11.7%. People who lack health insurance often do not receive any type of preventative medicine or care. They often arrive in emergency rooms very ill, requiring and receiving very expensive care that is funded from the free care pool or by the hospital itself. This type of health care thus drives up the cost of health care for everyone. There are three plans being discussed in Massachusetts: one from the Governor, one from the Senate, and one from the House of Representatives. All three plans would cover either part or all of the uninsured within two to three years, the Senate plan being the most conservative. The plans proposed by the Governor and by the House would require individuals to purchase health insurance, with exclusion for the poor who cannot afford to do so. The House plan would add a payroll tax to employers of more than 10 workers who do not offer health insurance. The Senate version does not require individuals to purchase health insurance and only requires that employers of more than 50 workers be required to provide insurance or else reimburse the state’s free care pool if that is used to pay for one of their worker’s health care needs. All three plans would encourage private insurers to offer a type of scaled-back health insurance that would be affordable to the poor, to small businesses, and to individuals who don’t qualify for Medicaid. There were many late nights at Beacon Hill over the last few weeks as legislators worked on the various proposals. The House and the Governor’s plan would involve high deductibles in order for the monthly premium to be affordable. The Governor would like to see monthly premiums as low as $200 a month, with deductibles of perhaps $500 to $1000. In addition to discussing covering the uninsured, the Senate President proposed expanding Medicaid to cover households that are up to 300 percent of the poverty level, up from the current limit of 200 percent. Disclosure of Medical Mistakes Senator Moore, Co-chairman of the Joint Commission on Health Care Financing, is drafting a bill that would require hospitals to reveal to the public when a “never event” happens. A “never event” is defined as mistakes that should never happen, are rare, but are serious and preventable. Included in the list is surgery on the wrong part, surgery on the wrong patient, or the wrong surgery being performed. A similar measure was enacted in Minnesota this year. In addition to reporting errors, hospitals in Minnesota may not receive payments from insurers for costs due to “never events.” Medicare Drug Benefit Starting November 15th, senior citizens are able to enroll in the new Medicare drug benefit plan due to take effect in January 2006. Participants have several options to choose from and the process is confusing to even health care experts. In addition, drug plans are being offered by about 17 companies, as well as drug coverage offered as part of the Medicare Advantage plan. At issue is the “doughnut hole” part, in which the consumer may be required to pay 100% of the cost of medications, if the cost for them is between $2250 and $5100. Costs either above or below this are covered at least in part by the new Medicare drug benefit plan. There are several information sessions being held across the state to assist seniors in this process. Mayflower Fall 2005 Volume 16 Issue 4 Governmental Affairs Maureen F. McLaughlin, BSN, RN, CPAN Uninsured in Massachusetts The number of Massachusetts residents without health insurance rose last year, increasing at a rate faster than the rest of the country. According to the federal Census Bureau, the number of uninsured residents in Massachusetts rose to 748,000 last year, an increase of 66,000 from 2003. Across the country, the national average for the uninsured is 15.7 % of a state’s population. In Massachusetts, the number is 11.7 % of the state’s residents lack health insurance. A possible cause for the increase in the number of the uninsured is employers raising the cost of health care coverage to their workers, to the extent that the worker can no longer afford it. Another cause could be an employer dropping coverage. A key element to remember in these numbers is that they include Massachusetts residents who are employed. Governor Mitt Romney has made the issue of health insurance a major part of his legislative agenda this year. A recent Romney proposal scheduled for a vote this month involves changes to the free care pool. Governor Romney has proposed that those who receive free health care and lack any form of health insurance begin to pay a co-payment, or fee, for their health care treatment. The proposed fee structure is from $3 to $5. Governor Romney has stated that he hopes this measure will encourage those without any health insurance to enroll in Medicaid and thus end a system of completely free care. In the current system, hospitals are reimbursed for these patients through the Uncompensated Free Care Pool. (Boston Globe, September, 2005) Funding For Nursing Education Thousands of registered nurses convened on the State House July 13 to support Senate Bill 1260, sponsored by Senator Moore. SB1260, ‘an act to promote safe patient care and support the nursing profession’ would, if enacted, increase funding for nursing education. An estimated 32,000 qualified applicants were turned away from nursing programs last year. Key elements of the Bill would create the Clara Barton Nursing Excellence program, which would include loan repayment, scholarships, and mentoring. This Bill would also assist in the expedited hiring of nursing faculty in the state college system. There is also a section aimed at hospitals, requiring that their staffing be “transparent,” that staffing plans be posted in common areas that can be viewed by the public, and that performance measures be obtained on nurse sensitive issues, including patient care hours per day. Mandated Staffing Ratios On the same day as supporters of Senate Bill S1260 gathered at the State House, the MNA and others gathered to provide testimony in support of House Bill 2663, a bill that would establish mandated staffing ratios. Both groups gathered in a large auditorium and testimony in front of the Public Health Committee. Pre-designated, alternating groups of nurses were called upon to provide testimony in support of either SB1260 or HB 2663. No decision was made at the end of the long day. A separate sub-committee has been formed to review the testimony and both measures, and to attempt to create a compromise bill. FDA Warning The government is investigating 120 deaths presumably related to the use of the fentanyl patch. Some of the deaths were presumed to be accidental overdoses, but concern was raised that patients and families not fully understand potentially harmful side effects, including trouble breathing and respiratory depression. The fentanyl patch is primarily used for round- the-clock pain and should not be the patient’s first narcotic painkiller.