By Andy Metzger

STATE HOUSE NEWS SERVICE

STATE HOUSE -- A voter referendum that would mandate one nurse for every four patients was touted Monday as a means of returning safety to hospitals and simultaneously dismissed as a clumsy tool that would drive up costs and deplete resources from pharmacy, home visits and physicians.

Before potentially moving onto the November ballot, two voter initiatives were before the Committee on Health Care Financing where opponents and proponents argued the merits and occasionally broke into applause.

"Our hospitals are different and so are the communities we serve," said BayState Health CEO Mark Tolosky. He said, "All these differences cannot be accommodated in a rigid formula model."

Margaret Browne, a nurse at Berkshire Medical Center, said she left her job in the emergency room to work in the recovery room where the one-to-one nursing ratio allows her to guarantee patients' safety.

"The emergency room at Berkshire Medical Center - top 25 in the nation; top 2 percent in the state - is not a safe place to be. It is not a safe for me; it is not safe for patients," Browne said. "I left there because I had too many near-misses, witnessed and participated in."

Browne said the Pittsfield hospital is the only hospital within a 45-minute drive in any direction.

Nurses filled the Gardner Auditorium wearing blue Massachusetts Nurses Association shirts and cheering on the several Democratic lawmakers who argued in favor of legislation to set minimum ratios, warning that a failure to act would put the question before voters.

"Every time we try to bring this issue up, the health care lobby, and they're all here today on the other side, will want to make sure this bill doesn't go anywhere," Sen. Marc Pacheco, a Taunton Democrat, told the Committee on Health Care Financing. "But there's a choice this year, Mr. Chairman. There's a choice. You see, there's a ballot question that's also before you today."

There was less discussion on Monday about another initiative petition (H 3844) seeking to limit the pay of certain hospital executives, though AFL-CIO of Massachusetts President Steve Tolman backed the measure in testimony mostly devoted to supporting the nurse staffing legislation.

"As supporters of the initiative to increase the minimum wage, we are appalled that we allow taxpayer dollars to be used to pay hospital CEOs more than 100 times the wage of their lowest-paid worker," said Tolman.

Bills filed by legislators (H 1008/ S 557) and also heard on Monday would empower the Department of Public Health to set minimum staffing ratios, while the measure headed for the November ballot (H 3843) would set a maximum of four non-urgent stable patients for each nurse.

"There is a limit to the number of patients a nurse can care for safely," said Rep. Denise Garlick, a Needham Democrat and registered nurse.

Brigham and Women's Hospital Associate Chief Nurse Joan Vitello-Cicciu described how her hospital reacted to the massive injuries caused by the Boston Marathon bombing, assigning nurses not based on staffing levels but based instead on the "skillset and competency" of the nurses on staff.

"This is what nursing leaders do best. We adjust our staffing," said Vitello-Cicciu, who is president-elect of Massachusetts and Rhode Island Organization of Nurse Leaders President-elect and said Brigham received 31 injured patients, including 23 in the first hour with deep wombs and nearly severed limbs. No Boston hospital lost any of those injured patients, she said. She said the proposal is "a recipe for waste."

Rep. Denise Provost, a Somerville Democrat, said nurses' current workloads drive people out of the profession, and said it can be difficult to find a nurse at hospitals sometimes.

"I think we've all had the experience at times of finding that it is difficult for a patient, even in a time of great need, to get attention, to get a staffer in," Provost said.

Karen Coughlin, a nurse at Taunton State Hospital, said a friend of hers told her of a recent shift where she was the only nurse on from 3 p.m. to 11 p.m., handling a range of different services for 17 to 18 patients.

"I just think that's absolutely sinful," Coughlin said. She said, "She's not Superwoman."

Coughlin told the News Service her friend had been working at an Arbour medical facility.

UMass Memorial Medical Center President Patrick Muldoon said the bill would cost the hospital $60 million, though he was unable to provide specifics about how that cost breaks down.

"Health care is a team effort," said Muldoon, who said the law shouldn't be used "in place of the professional judgment of nurse leaders on the floor and by the bedside."

Rep. Marjorie Decker, a Cambridge Democrat, drew howls of delight and applause, when she suggested to a panel of hospital executives that nurses who work more closely with patients would be more knowledgeable about the issue than "CEOs."

"I know you're making fun of us, but we all worked at hospitals at one time," said Massachusetts Hospital Association President Lynn Nicholas, who said the nurses' push for minimum staffing focuses only on that aspect of health care, ignoring the other variables.

"It's just oversimplification to say it's only about more nurses," said Nicholas, who said in the future, hospitals will be smaller and home-visits would become more common. She said, "More and more of the care will be in the home setting."

In 2012, the Legislature passed a health reform law aimed at controlling costs, providing more oversight to the health market and encouraging new methods of care. The law also prohibited hospitals from requiring nurses to work overtime except in emergency situations.

Boston College nursing professor Judith Shindul-Rothschild, a supporter of the legislation, suggested profits are the driving force for the bill's opponents, saying hospitals with the worst nurse staffing have double-digit profits.

"It simply means shifting resources within a hospital," Shindul-Rothschild said. She said most hospitals already abide by the staffing that would be mandated by the legislation.

Nicholas said she and others had previously met with nurses' representatives "over and over in secret," even keeping the meetings from their boards, and said they could not agree on across-the-board minimum staffing requirements.

"It was those three little words 'at all times' that was the stumbling block," said Nicholas.

When Decker asked Shindul-Rothschild about the meetings, she said, "I signed a confidentiality agreement."

Tolosky said health costs would "explode" if the bill becomes law, and said California is the only state that has such a law on its books.

Dean Florez, the former California state Senate majority leader who said he was a deciding vote on the 1999 legislation, told the committee that he and others were worried about what effect the staffing mandate might have on hospitals.

"A decade later, I think it's doing quite well," said Florez, who said it can be "tough" to be regulated. He said, "All of our hospitals are still in great shape."

The League of Women Voters supports both initiative petitions, while the Associated Industries of Massachusetts is opposed to mandated staffing level.

"Codifying in government regulation staffing levels for any entity is misguided, counterproductive and costly," wrote AIM Vice President of Government Affairs Kristen Lepore in a Monday letter to lawmakers. "It is undeniable that the complexity of determining appropriate nurse staffing levels for any health care institution involves myriad factors and expert judgments that cannot be adequately reduced to regulation. For all employers, appropriate staffing levels are best determined at each respective workplace."