2 November 2018
Dear Interested Readers,
Question One On The Massachusetts Ballot Has Lessons To Teach Us
I am probably prejudiced against ballot questions, or if you prefer, voter referendums. The disaster for the United Kingdom, Brexit, may be the best example of how they can lead to nothing good. Sometimes they are “non binding” and the potential for damage is reduced to the transient effect on public opinion, but it seems to me that most of them represent a larger failure of the legislative processes of a representative democracy.
Most of the ballot questions that I can remember have had to do with property tax policy, issues that effect the LGBTQ community, or the legalization of marijuana. I was surprised to learn by spending a little time on the Internet that ballot questions are now appearing on a wide variety of issues that include animal rights issues, business issues, prisons, housing, welfare policy and benefits, healthcare including assisted suicide and abortion, affirmative action, public support for the arts, veterans issues, and now staffing ratios for nurses in hospitals.
Since there are more and more international readers of these Healthcare Musings, and not all of my domestic readers were listening in their eleventh grade civics classes, perhaps I should give you Wikipedia’s definition of ballot questions or ballot measures.
A ballot measure is a piece of proposed legislation to be approved or rejected by eligible voters. Ballot measures are also known as “propositions” or simply “questions”.
Ballot measures differ from most legislation passed by representative democracies; ordinarily, an elected legislature develops and passes laws. Ballot measures, by contrast, are an example of direct democracy.
In the United States ballot measures may be established by several different processes which vary amongst the states:[1]
- Initiative, in which any citizen or organization may gather a predetermined number of signatures to qualify a measure for the ballot;
- Popular referendum, in which a predetermined number of signatures (typically lower than the number required for an initiative) qualifies a ballot measure repealing a specific act of the legislature;
- Legislative referral (a.k.a. “legislative referendum”), in which the legislature puts proposed legislation up for popular vote (either voluntarily or, in the case of a constitutional amendment as a required procedure).
Perhaps the biggest issue to understand is that most of the time our government functions as a Representative Democracy. We elect representatives to do our business, make our laws, define our social services, declare wars, and tax us to support programs that will be of benefit to the greater good. From the beginning, going back to the Greeks, and certainly at the founding of this nation, there has been great controversy over who should participate in the development of policy and the making of laws. There has always been some concern about throwing the big questions to the judgement of the entire community. That is why we have an electoral college for the selection of the president and why state legislatures selected senators until the 17th Amendment was passed in 1913. The founding fathers were extremely apprehensive about the potential instability and abuse of rights for minorities in a “Direct Democracy” where everybody has a say in the outcome and the majority rules. This concern existed as they drafted the Constitution, even though the classic New England town meeting is a good example of a Direct Democracy. James Madison wanted nothing to do with Direct Democracy, and we do not have a constitutional mechanism to do referendums except that some states used a referendum to ratify the 21st Amendment which repealed the 18th Amendment prohibiting the use of alcohol. Twenty six states and the District of Columbia do have constitutions that allow ballot questions. Massachusetts does.
This year Question One on the Massachusetts ballot asks for ratification of a ballot initiative that would establish nurse to patient ratios in all aspects of hospital care from the EW to the NICU. The question is the product of the efforts of the Massachusetts Nurses Association (MNA), and their idea is vigorously opposed by most hospital administrators. Millions of dollars have been spent by both sides to confuse or convince the public. I have been asked by many people for advice about how to vote on the issue. For a while I tried to give an answer, but then gave up when I realized that there was no right answer.
The advertising campaigns for both sides have been fierce, but it appears that the nurses will lose. According to recent polls 58% of voters oppose the idea of regulated staffing ratios. Since the question has probably been decided, an opinion is not nearly as valuable as an analysis. Perhaps I should wait until after the election, but the question has gotten me thinking, and it feels like now is the time to express myself.
Like James Madison suggested in Federalist Paper 10, I am apprehensive about the ability of plebiscites to generate good policy. The 2008 California Ballot Question that disallowed same sex marriage is as good example as any of how a ballot question can threaten the human rights of a minority. Brexit is the perfect example of a question that is so complex that the possibility of a majority making the right decision approaches a coin toss. The significance of Question One is not what the outcome will be, but rather the opportunity to understand the situation that led to the question ever being posed. Question One suggests that there is a tension between what is best for patients and the nurses and other professionals who care for them, and the cost of care.
The Health Policy Commission of Massachusetts has come out recommending the defeat of Question One based on how much passage would add to the cost of care in Massachusetts. The HPC used the experience in California to estimate that if passed the measure would require an addition 3000 nurses and cost over $900 million dollars a year. More damning was testimony from the California experience that questioned whether the additional expense improved the quality of care.
As I look at the question, I think it represents a sad situation. It is too easy just to say it represents a dilemma, a choice between unacceptable alternatives. On the one hand it is logical that reducing the number of patients that each nurse must care for would be better for both the patients and the nurses. It is equally logical to conclude that adding more personnel to any hospital’s budget will create financial pressure, especially if the increased cost in the personnel line of the budget is not balanced by some savings or increase in revenue.
My point is that the current dilemma is more likely the result of misuse of the hospital resources and the finance mechanisms that drive that misuse. I realize that my opinion means nothing, and that current finance mechanisms and current staffing controversies are likely to continue. I have had the concern that in the future workforce issues would become a greater problem than revenue or finance issues. I have been saying for some time that the financial crisis in healthcare is a function of the operating system (how we organize practice and deliver care) and healthcare finance. I’ve been saying that because I believe that Dr. Robert Ebert was right when he said over fifty years ago:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
The solution to the problem that the nurses at the MNA are trying to solve with their ballot initiative is a response to the reality that as revenues fail to climb as fast as costs, hospital administrators can only balance their budgets by asking each nurse to take more patients. The personnel line in a hospital budget is both a potential source of red ink and an opportunity in the battle that they must win to maintain solvency if revenues are reduced by a downward trend in FFS payment. Cutting staff, cutting services, and raising prices are responses that seem to be preferred by management to innovation, waste reduction or elimination, and rethinking the processes and optimal locations for care delivery.
One potential answer is to make the hospital a cost center in a larger system of care and move the source of revenue from the number of hospital services provided to the number of patients served (population), patient satisfaction, and outcomes. We have known this fact for years. What prevents the change?
We do not like change. Peter Drucker observed the reality that all businesses hang on to old ways long after those products or services fail and will attempt to tweak what is not working rather than embrace the opportunities of transformation and innovation. Question One no matter how the vote comes down is an attempt to tweak an “old way” rather than imagine a better way. Perhaps the data from California that suggests that mandated staffing ratios don’t improve care is related to the fact that hospitalization in a broad sense doesn’t offer much long term benefit for many of those who are hospitalized. We misuse the hospital when we make it the alternative to better management for conditions that are sensitive to ambulatory management like CHF, diabetes, and COPD. In fact we know that the errors that occur in the hospital are a major contributor to mortality. A huge number of the patients that add to the burden of care for nurses in the hospital are there because of failures in the delivery of care in the ambulatory environment. Those same patients do not fare well in the hospital.
Perhaps the ballot question that should have been given to voters next Tuesday is whether or not FFS reimbursement will no longer be allowed in Massachusetts. The legislature passed Chapter 305 in 2008 which was a thoughtful attempt at statewide transformation incorporating many of the concepts of Crossing the Quality Chasm. At the time many of us imagined that by 2013 value based reimbursement would be the primary form of finance. It was a plan without a will to make it happen. It was easier to go through the motions and stay with the past. Now we have hospitalized patients who lack the attention they need. We have nurses who are exhausted and worry about the care that they do not have the time to deliver. We have healthcare executives who can see reducing personnel expenses as the only way to a positive bottom line.
The question to ask is how long can our preference for delivering care in the hospital, especially in the most expensive academic medical centers, persist against the rising costs? I fear that it may last a long time. If we are willing to ask nurses to do more, and see no problem with patients getting less as a way to balance the books, rather than look for ways of better deploying nursing and financial resources to improve care by testing new models of care, then we will continue to see costs rise and quality fail to improve. The nurses were right to point out the problem. A solution that will produce better care and move us incrementally toward the Triple Aim will require much more change than hiring 3000 nurses and spending 900 million dollars.
Halloween and Other Scary Things
Our town likes Halloween. Most of the merchants and even some of the churches create Halloween scenes out in front of their establishments. There is a competition for the best display. I have not heard yet who the winner was, but I did enjoy riding around looking at the offerings. Here is my favorite display:
The building is now used as a gift shop, but it was once the general store at the center of town. I know that it is hard to appreciate all of the creativity in the scene from the picture, but I hope that it wins. I think that I like it because all the characters seem happy, not scared. The little house with the witch on top is cute and more intriguing than frightening. Last Friday night, just before the Red Sox began losing the only game they would lose to the Dodgers, the children of our town were running up and down Main Street and knocking on the doors of the houses on the streets that are near the center of town doing their “trick or treating.” The town had decided that a controlled event on a Friday was better than a random event midweek. We are about two miles from the center of town and have never had our doorbell rung by a ghost, a princess, or even a Star Wars character. I wish that were not true. I always loved Halloween.
Today’s header is a scene that caught my eye because it looks “naturally scary.” I am old enough to have seen the “Rocky Horror Picture Show” during its long run on Friday nights at the Exeter Street Theater in Back Bay back in the 70s. Some of you may actually have shown up in costume or yelled out the lines as you saw it for the umpteenth time. You probably remember the story. For those Interested Readers who were born too late to have been a participant in the phenomena that surrounded the movie in many American cities, the stars of the movie are Tim Curry, Susan Sarandon and Barry Bostwick. Here is a brief synopsis of the story provided by Wikipedia.
The story centers on a young engaged couple whose car breaks down in the rain near a castle where they seek a telephone to call for help. The castle or country home is occupied by strangers in elaborate costumes celebrating an annual convention. They discover the head of the house is Dr. Frank N. Furter, an apparent mad scientist who actually is an alien transvestite who creates a living muscle man in his laboratory. The couple are seduced separately by the mad scientist and eventually released by the servants who take control.
The gates of “Chetwood,” the name is barely visible on the stonework, look pretty scary on almost any day and give no clue to what lies down the road out of sight. Would you have the courage to walk through those gates and down that drive to ask for help if your car broke down on Davis Hill Road on some dark and rainy night in late October? I can’t even muster the courage to take a look down the road in broad daylight, even though I have walked past those gates frequently on many of my walks.
The gates suggest another era and a level of wealth that exceeds my experience. I read once that the ultra rich and the ultra poor both live out of site of the rest of us. The really rich are “up and out of site” behind gates and down roads that are so long that you can’t see their houses. There are several old estates on Lake Sunapee, like Chetwood, that match that description. The ultra poor are the mirror image of the ultra rich. They live “down and out of site.” It is almost as hard to find them. I have seen their rusted mobile homes and small dilapidated houses located in the woods on back roads long past where “the hardtop meets the clay.”
I must confess that after walking past Chetwood for years and wondering what lay down that road, I turned to Google Earth. I was disappointed. Google does not look through trees very well. There appears to be a very large house that is set back about a hundred yards from Lake Sunapee. I guess that it is still possible that through those gates and down that road there is a haunted house from another era. Trust me I will not venture down that road to find out for sure.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
