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Boston Capital

Nursing a conundrum

By Steven Syre
Globe Columnist / March 25, 2011

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All the big-picture policy talk about controlling the cost of health care runs smack into the real world at the hospital nursing station.

This is true across the country, but especially in Massachusetts, where nurses are pressing several hospitals in contract talks. Two negotiations in particular — at Tufts Medical Center in Boston and St. Vincent Hospital in Worcester — are focused on staffing levels for nurses.

Hospital administrators say they are trying to manage in challenging times, reorganizing work to become more efficient while maintaining the quality of care. Many nurses and their union say the practical result of efficiency plans is a thin staff that put patients at greater risk.

“The hospital has set us up to fail,’’ says Barbara Tiller, a long-time nurse at Tufts and chairman of the union bargaining committee there. “It’s not possible to take care of people like parts on a factory line.’’

Everyone from the governor to executives running the state’s big insurance companies are leaning on health care providers to slow the increase of medical costs. Hospital administrators look at their budgets and see labor as the thickest slice of the pie by far. Inside the payroll numbers, nurses are the biggest expense and a natural target for cost control.

“We think of hospitals as very technological, but labor is still over half the cost,’’ says Jack Needleman, a professor at the UCLA School of Public Health. “In an environment where you’re trying to control costs, hospitals quite understandably apply the Willie Sutton theory.’’

That means going where the money is, and Needleman says nursing payrolls can make up as much as 25 cents of a hospital-budget dollar, though the Massachusetts Nurses Association puts the statewide figure at about 17 cents. Nurses are a major expense because hospitals employ lots of them at good full-time salaries — nearly $96,000 a year on average at Tufts (the union places the statewide average for members who are hospital nurses at $82,000).

Hospital executives often promote sophisticated strategies to curb medical costs, from aggressively managing small groups of the most expensive patients to targeting a handful of health problems that account for much of the big-ticket volume. Truth is, any hospital chief who needs to save money soon will go first to the budget and look for big targets.

Tufts is no stranger to financial challenges, and it’s feeling the squeeze on several cost-containment fronts. In particular, the hospital says it now receives $18 million a year less in Medicaid payments from the state than two years ago. Tufts president Ellen Zane says the hospital is trying to adapt to a new, leaner medical world.

“The governor has put forth a health care plan that basically says everyone needs to be more creative, get their heads out of the sand and understand we can’t turn back the clock,’’ says Zane. “That responsibility is put on all of us, including the union.’’

In fact, Tufts has been trying to change its “care delivery model’’ for about two years and considers that efficiency project a work in progress. An internal hospital presentation that goes back a year or more listed a series of project objectives. One of them: Cut daily costs for each patient by $34.

Tufts executives want the nurses union to agree to a one-year contract to complete that work. They balk at the idea of mandated nurse-to-patient ratios.

On paper, improving nursing efficiency at hospitals seems like a worthwhile goal. Among the most basic ideas: Push more unskilled work to other employees.

But it is hard to say how those efforts actually work on a hospital floor. Tufts executives point to their consistently high quality ratings, but nurses cite hundreds of complaints they have written out over specific staffing problems.

A study by Needleman at UCLA and others, published last week in the New England Journal of Medicine, reviewed nearly 200,000 admissions at an unnamed academic medical center and found an increased risk of patient death when nursing shifts were staffed below optimal levels.

“The concerns the nurses are raising are real,’’ says Needleman. “But the cost pressure is real too. How one solves that is an issue.’’

That’s not a message you will read on a picket sign or hear from a hospital administrator. It’s one of many real-world conflicts that will emerge as we try to slow the growth of health care costs.

Steven Syre is a Globe columnist. He can be reached at syre@globe.com.