Advocacy Correspondence: PA House Health Committee, Opposition to House Bill 106

June 1, 2023

Honorable Health Committee Members
Pennsylvania House of Representatives
326 Main Capitol Building
Harrisburg, PA 17120-2023

Dear Chairman Frankel, Chairwoman Rapp, and Members of the Committee:

On behalf of more than 230 members statewide, The Hospital and Healthsystem Association of Pennsylvania strongly opposes HB 106, which, among other provisions, would set government- mandated RN-to-patient staff ratios across all hospital units. We understand that you will be considering this bill on June 6 and we respectfully urge you to vote no.

We appreciate the intention of this legislation and share a deep and fundamental belief in the value of the commonwealth’s nurses. Our nurses endured the most prolonged and devastating event of our lifetimes, and they remain there for us now, caring for the people we love when they need it most. Pennsylvania’s nurses are exhausted and they need our help.

Government-mandated ratios do not provide the help they need.

The American Nurses Association asserts that “appropriate staffing is a dynamic process that aligns the number of nurses, their workload, expertise, and resources with patient needs in order to achieve quality patient outcomes within a healthy work environment.”ⁱ The American Organization for Nursing Leadership affirms that mandated nurse staffing ratios are a static and ineffective tool that cannot guarantee a safe health care environment, limit innovation, and increase stress on a system already facing a shortage of educated nurses.ⁱⁱ Ratios do not produce more nurses; do not respect practicing nurses’ clinical judgment and skill; do not factor in other staff or resources; and do not reflect the real-world complexities associated with providing 24/7/365 acute and emergency care.

Staffing ratios have unintended consequences. Given the well-documented, nationwide shortage of bedside nursesⁱⁱⁱ, this bill will put Pennsylvania hospitals in the impossible position of having to choose between turning patients away or breaking the law at the risk of losing their licenses. Already stressed emergency department providers will operate at the intersection of federal law, which mandates that they care for every person who presents for treatment, and state law which will sanction them for doing so when the government-required staffing level cannot be met. Our rural hospitals—more than half of which have 100 beds or fewer—will face particularly difficult questions about how they will remain open in the face of a state mandate they cannot meet.

Patient safety and quality care are the most important hallmarks of our health care system. Safe hospital staffing standards are addressed frequently in regulation and considered by a number of Department of Health requirements, Title 28, Chapter 109,^iv including Sections 109.4 (sufficient number of nurses shall be on duty); 109.6 (staffing schedule requirements), 109.7 (nursing service organizational plan), and 109.7 (role of nursing representatives in hospital planning), among others.

Federal regulations also require Medicare-certified hospitals to ensure that adequate numbers of nurses provide patient care as a condition of participation.

Hospitals focus on managing patient populations to align with staffing constraints. You have heard from frustrated constituents that hospitals are increasingly working through extensive wait times, delaying procedures (when safe), closing beds, reducing services, transferring patients, and putting their emergency departments on “divert” status to incoming patients. Such measures are due, in large part, to align available staff with high-quality care delivery.

Ratios do not solve the core problem: There simply are not enough nurses. Eighty-four percent of hospitals report that “finding qualified professionals” is the top barrier to hiring more nurses.v Even without potential government mandates, Pennsylvania’s RN gap is projected to be the worst in the nation, with a shortfall of 20,345 nurses within the next three years^vi. The assertion that a government mandate will immediately shift the employment patterns of tens of thousands of professionals—across a complex mix of specialties and geographic areas—is simply not plausible.

Pennsylvania hospitals are taking decisive action to recruit and retain nurses. Despite significant sign-on bonuses—often more than $30,000—increased wages, higher shift differentials, more flexible scheduling options, education support, and other incentives, average vacancy rates for direct care RNs exceed 30 percent across the state.^vii

Many hospitals are fundamentally changing their care models to better support bedside RNs. This includes examining nursing work and deploying virtual and team-based approaches, for example, that ensure staffing levels meet the needs of patients and their communities. These decisions—made at the community level—provide patients with the right care at the right time. Staffing ratios take these decisions away from local clinicians and create new barriers to care.

Only California has mandated nurse staffing ratios across all hospital units. Their experience reveals that government-mandated ratios:

• Do not end workforce shortages: California’s shortfall is projected to be 44,500 nurses by 2030^viii
• Do not solve nurses’ short-staffing concerns: California nurses continue to experience challenges^ix
• Do not improve the quality of care: California ranks lower in overall care quality than Pennsylvania^x
• Do not increase access to care: California ranks 46th in beds-per-capita, Pennsylvania ranks 18^{th xi}
• Do not reduce cost of care: a day of a nonprofit hospital care in California is $4.6k, Pennsylvania is $2.9k^xii

There are better solutions than staffing ratios. To meaningfully help practicing nurses, we must enact policies and make investments to develop more nurses to care for Pennsylvania patients by the bedside.

Working together, we can increase Pennsylvania’s ability to educate nurses by assessing clinical experience as a viable pathway to credentialing nurse educators; supporting nurses who seek the advanced degrees necessary to teach; reducing disparities between higher bedside pay versus lower nurse educator pay; incentivizing preceptorship; and authorizing additional locations as suitable for clinical education experience. Pennsylvania has more than 1,700 health care training programs, 400 nursing programs, and nine medical schools.^xiii Many nursing programs have indicated that they have waiting lists and could serve more students if they could attract additional instructors and offer more clinical opportunities.

Financial proposals—scholarships, discounted tuition, student loan relief, tax incentives—can be targeted toward current and future nurse educators and nurses who commit to remaining in Pennsylvania and working by the bedside.

You can continue working closely with the Governor to operationalize the interstate licensing compacts and to reform the commonwealth’s licensing and credentialing processes. Pennsylvania hospitals—particularly those near borders with other states—report losing qualified candidates during the hiring process because job seekers find it easier and faster to become licensed and start work elsewhere.

The commonwealth can create a “Pennsylvania Health Care Workforce Council” to develop short- and long-term strategies to address the commonwealth’s health care workforce shortage. The council should assess current and projected workforce needs and help cultivate a pipeline for a diverse and culturally competent workforce. The council should also establish a “one-stop shop” for health care educators and employers to meet the requirements of multiple state agencies.

As government leaders, you work closely with your local hospitals. You are well aware that many are navigating profound financial strain and some are just barely keeping their doors open. With historically high staffing, pharmaceutical, and supply costs and exceptionally low public reimbursement rates that do not even cover the cost of care, hospitals are operating in an unsustainable fiscal environment. The difference between care-related expenses and revenues is far below pre-pandemic levels, even when federal pandemic relief is included. Nationally, more than half of all hospitals lost money on care last year. Government-mandated ratios will effectively force Pennsylvania hospitals to close beds or reduce services, and, in many communities, put entire hospitals at risk.

HAP remains committed to working with you to craft and enact meaningful solutions that can get more nurses by the bedside, build our workforce for the future, and ensure our communities have access to outstanding care throughout the commonwealth.

Sincerely,

Andy Carter
President and Chief Executive Officer

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ⁱ https://www.nursingworld.org/~499b62/contentassets/568122c62ddc44bea03b11a71f240a50/nurse-staffing-task-force-imperatives-recommendations--actions.pdf
ⁱⁱhttps://www.aonl.org/resources/policy-statement-nurse-staffing
ⁱⁱⁱhttps://www.ncsbn.org/news/ncsbn-research-projects-significant-nursing-workforce-shortages-and-crisis
^ivhttps://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/028/chapter109/chap109toc.html&d= reduce#:~:text=%C2%A7%20109.4.&text=A%20sufficient%20number%20of%20registered,skills%20of%20a%20registered%20nurse
^vhttps://www.haponline.org/Resource-Center?resourceid=941
^vihttps://www.mercer.us/content/dam/mercer/assets/content-images/north-america/united-states/us-healthcare-news/us-2021-healthcare-labor-market-whitepaper.pdf
^viihttps://www.haponline.org/Resource-Center?resourceid=941
^viiihttps://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/nchwa-hrsa-nursing-report.pdf
^ixhttps://www.beckershospitalreview.com/hr/california-nurses-sound-alarm-on-staffing-6-recent-cases.html
^x https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr.pdf
^xi https://www.kff.org/other/state-indicator/beds-by-ownership/ ?currentTimeframe=0&sortModel=%7B%22colId% 22:%22Total%22,%22sort%22:%22desc%22%7D
^xii https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day-by-ownership/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
^xiii https://haponlinecontent.azureedge.net/resourcelibrary/fy2021-economic-analysis-white-paper-10072022.pdf

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Topics: State Advocacy, Workforce

Revision Date: 6/1/2023

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