Testimony of the New York State Nurses Association, delivered by Shaun Flynn,
to a joint legislative public hearing, 3 March 2011.
Good afternoon. My name is Shaun Flynn and I am the Director of Governmental Affairs at the New York State Nurses Association. Joining me today is Sally Dreslin, a registered nurse, and an Associate Director in the Governmental Affairs Department. The Nurses Association is the oldest and largest professional organization for registered nurses in New York State. It represents the interests of more than 270,000 registered nurses and serves as the collective bargaining agent for more than 36,000 RNs at 150 healthcare facilities. On behalf of our members and the patients they serve, I appreciate the opportunity to address the Governor’s 2011-2012 Executive Budget as it relates to healthcare issues.
The Nurses Association appreciates the challenge involved in developing a balanced budget in light of the State’s fiscal insecurity. However, we are exceptionally concerned that the choices made during the evolution of this year’s budget, and particularly the Medicaid Redesign Team process, have the potential to significantly and negatively impact patient safety, the provision of healthcare services in the state and the practice of registered nurses throughout New York. If implemented all at once, the reductions proposed by Governor Cuomo will have a severe effect on the state’s most vulnerable residents, drastically reducing access to services, increasing morbidity and ultimately adding to long-term healthcare costs.
Though the Medicaid Redesign Team has engaged mostly provider and some consumer stakeholders, among others, in seeking appropriate ways to reduce Medicaid costs, many of the solutions proposed are likely to require long-term restructuring. Medicaid reform in New York must focus on reducing costs through better coordination of care, improved outcomes, and the control of fraud, waste and abuse of the program, rather than on an abrupt reduction of more than $2.35 billion in spending. With the right solutions, we can improve care and manage costs.
NYSNA participated on the Medicaid Redesign Team and, against the backdrop of severe across-the-board cuts that had been threatened by the Administration, we supported a package of proposals that included some profoundly flawed recommendations. The last-minute change to the Redesign Team’s process that resulted in the elimination of time for deliberation and also of the ability to amend individual proposals was not in the public’s best interest. NYSNA has significant concerns with proposals that seek to expand the roles of healthcare personnel beyond that for which they have been educated and prepared; proposals that further challenge the ability of safety-net providers to offer accessible, quality care and the proposal to suspend the Nursing Care Quality Protection Act which was sponsored by many of you and which was signed into law in 2009. Many of the proposals that have been accepted by the Governor will require long-term structural changes and demonstrate no short-term savings, yet they have inexplicably been included in the accepted, short-term package of recommendations without any opportunity for deliberation or amendment.
The Medicaid reform package that the Governor has accepted foreshadows an increasingly precarious healthcare delivery environment. Medicaid providers, healthcare workers and Medicaid enrollees have endured across-the-board reductions in reimbursement rates year after year and the results are closed facilities; under-staffing; poorly coordinated care, fumbled care transitions; cuts in community supports and decreased access to health care among the state’s neediest residents. Under the global spending cap with its ill-defined “utilization controls” and rate reductions that the Department of Health will be empowered to implement, facilities that are already in a brittle fiscal state may not be able to endure the further restriction of resources needed in order to fulfill their missions. New York State must respect the commitment that it has made in its Constitution to the aid, care and support of the needy. The safety net represented by Medicaid, while far from a perfect healthcare delivery model, is crucial to the health and well-being of millions of state residents who have no other viable alternative for care.
The future of the Medicaid program must include healthcare homes that provide coordinated, primary and preventive health care for even the most complex and fragile recipients, and a process that holds plans and providers accountable (accountable care organizations, or ACOs) for not meeting established quality outcomes. Additionally, New York will serve itself well, in light of federal healthcare reform implementation, if the Medicaid reforms it enacts today are in line with goals set forth in the Affordable Care Act. New York must ensure that mental health services are provided on par with other services. All services whether acute, sub-acute, residential, or ambulatory, must be accessible and community-based and must include sufficient numbers of registered nurses to ensure they are safe and effective.
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The Nurses Association recommends several initiatives that we feel will contribute to the state’s ability to provide cost-effective, high-quality health care to the residents of New York.
NYSNA supports expanding enrollment in Medicaid managed care programs. The goal of enrolling more recipients in managed care is to engage them in medical homes and to provide them access to high quality, coordinated primary and preventive care services. The Medicaid managed care programs have been successful in improving the quality of care for the recipients enrolled, as measured by the state’s Quality Assurance Reporting Requirements (QARR) system. The challenge, however, is that the majority of the state’s most costly Medicaid populations are either not enrolled in managed care programs, or the most expensive portions of their care are carved out of the managed care program and are reimbursed on a fee-for-service basis. More of New York’s high-cost Medicaid populations, e.g. those with multiple, chronic co-morbidities; with persistent, severe mental illness; the disabled and the frail elderly, must be enrolled in programs that provide better-coordinated care.
Inadequate and poorly monitored nurse staffing practices jeopardize the provision of quality health care services, resulting in dangerous and costly medical errors, sub-optimal patient and resident outcomes, and higher rates of nursing staff turnover. Research demonstrates that safe staffing ratios and minimum hours of care are associated with lower patient mortality, decreased length of stay and improved rates of nurse retention. The Nursing Care Quality Protection Act that was supposed to go into effect on March 15, 2010, was intended as a mechanism to monitor facility staffing levels, staff mix and nursing quality outcomes. This important public safety measure is in grave danger of elimination via the proposal recommendations of the Governor’s Medicaid Redesign Team. We strongly urge the legislature to reject any attempts to roll back the Act’s provisions and to, instead, use the data for the purposes of evidence-based decision-making in matters of healthcare reform.
Nursing staff turnover is a persistent challenge for nursing and hospital executives. NYSNA is disappointed that this issue was not addressed by the Governor’s Medicaid Redesign Team and urges further consideration in longer-term reform planning. High rates of turnover, particularly among first-year nurses, costs facilities from $62,000 to $88,000 per nurse; costs patient access to safe and quality care; and costs the nursing profession by exposing new nurse graduates to high-stress, unsupportive work environments. In 2007, the average nurse turnover rate in hospitals was 8.4 percent and 27.1 percent of newly-hired nurses left their jobs within one year of hire. There are estimates that up to 40 percent of new nurse graduates leave their hospital jobs within one year of hire. Annually, healthcare organizations spent $300,000 in nurse turnover costs for every 1 percent increase in turnover; an average turnover rate of 8.4 percent translates to an annual cost of turnover for healthcare organizations of $2.52 million.
Nurse Residency Programs fill the gap between school and practice by providing continuing education, mentoring, reduced patient loads, and support that enables the new nurse graduate to successfully navigate the transition from novice to competent practicing nurse. These programs generally last one year and research shows that they lower the rates of nurse turnover; improve the quality of patient care through the development of nurses’ critical thinking, prioritization skills, professionalism, and improved ability to function in healthcare teams; and improve the retention rates of new nurse graduates.
Many hospital systems are in fact, beginning to implement residency programs, but more need to be encouraged. As Mary Beth Campo, the Chief Nursing Executive for Kaleida Health in Western NY stated in relation to the implementation of a grant-funded collaborative Nurse Residency Program for Kaleida Health, Erie County Medical Center, Roswell Park and the VA Medical Center, “Nursing leaders realize that the success of new nurse graduates is critical to the future of health care in our community and has become a priority for area health providers” (Buffalo General News, June 24, 2010).
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NYSNA encourages building partnerships between academic and clinical centers as a means of sharing valuable, yet scarce resources. Nurse-managed health centers are community-based health clinics that are managed by nurses; most are either independent non-profits or academically-based clinics that are affiliated with schools of nursing. Key components of nurse-managed health centers include that: clients have direct access to nursing services; advanced practice nurses diagnose and treat, and promote health and optimal functioning; services are client-centered; services are reimbursed; accountability and responsibility for client care remains with the nurse; and overall accountability for the center remains with the nurse executive.
Nurse-managed health centers serve patient populations who are least likely to receive consistent, coordinated care. This includes vulnerable people across the age continuum who are uninsured, underinsured, or living in poverty. As safety-net providers, nurse-managed health centers allow patients who are unable to pay for care, to be charged on a sliding scale or treated for free. As a result, nurse-managed health centers often struggle to remain fiscally sound.
Nurse-managed health centers also serve the population of advanced practice nursing students, as well as students in other healthcare professions. They provide workforce training opportunities in community-based, primary care. Opportunities for community-based clinical education pose significant challenges for the healthcare educational system and the issue has often been identified as one barrier to the development of an adequate healthcare workforce for the future.
A national collection of quality measures for nurse-managed health centers indicates that these centers meet or exceed national quality benchmarks, based on Healthcare Effectiveness Data and Information Set (HEDIS) outcome data. In fact, nurse-managed health centers’ quality outcomes are particularly high in areas of chronic disease management. Evidence-based research has shown that the advanced practice nurse providers at nurse-managed health clinics provide high-quality primary care and women's health with outcomes that are similar to, or better than, other primary-care and women's health providers.
Most significantly, the National Committee for Quality Assurance (NCQA), in its 2011 Standards for patient-centered medical homes (PCMH), now includes nurse practitioner-led practices as practices or providers who are eligible for NCQA Recognition as a Patient-Centered Medical Home. In January 2011, eight nurse-managed health centers in Pennsylvania received NCQA's recognition and certification as Patient-Centered Medical Homes. This designation is a significant testament to the quality of care that is provided by nurse-managed health centers and also, hopefully, signals a wider acceptance of this important healthcare delivery model. We encourage you to explore creative opportunities that will support both the healthcare workforce and the provision of quality care in New York.
School-based health centers utilize multidisciplinary teams of providers, including nurse practitioners, to provide comprehensive primary care, preventive care, and early intervention services to underserved elementary and high school children. A series of papers in the American Journal of Public Health in 2010 highlighted some of the outcomes that are associated with access to school-based health centers. These include: an increase in the use of primary care services, a reduced use of the Emergency Department, fewer hospitalizations, expanded access to and improved quality of physical and mental health care, greater engagement in health-promoting behaviors, and improved resiliency among the children and adolescents. The “improved resiliency” outcome is significant because resiliency is measured through important quality of life factors: attending and applying oneself in school, expressing feelings and emotions, expressing a feeling of hope in one’s life and in the future, involvement in organized recreational or vocational activities, and motivation to participate in counseling. School-based health centers can significantly and positively alter the course of a vulnerable child’s life and registered nurses play a key role in that process. We encourage the Legislature to facilitate both the expansion of school-based health centers and their appropriate reimbursement as patient-centered medical homes.
To ensure that New Yorkers are receiving the best quality care, it is essential that appropriate members of the healthcare workforce are providing the right care in the right place. The Nurses Association is deeply disappointed in the inclusion of proposal #200 in the Medicaid Redesign Team’s final package of recommendations. Proposal #200 inappropriately expands the scope of services of home health aides to allow them to administer pre-poured medications to patients who are not self-directing, recommends the introduction of medication techs into nursing homes for the purposes of medication administration and recommends a scope of practice change for licensed practical nurses to allow them to perform assessments in long term care settings. This recommendation is inconsistent with current Education Law; LPNs do not receive the education that is required to assess patients. The entire current LPN workforce would have to undergo a re-education process and be tested. The curriculums of the current practical nursing programs would have to be changed and this would represent an expense for the state. When the LPN scope of practice was changed to allow them to administer medications, some LPNs were not able to meet the competency criteria, resulting in a two-tiered LPN practice.
NYSNA encourages you to look behind the veil of potential short-term workforce savings to see the long-term sacrifices in patient care and well-being when members of the healthcare team are functioning in inappropriate spheres. Proposals that seek to allow unlicensed assistive personnel to administer medication in nursing homes or that would expand the services provided in the home setting by unlicensed assistive personnel, are short-sighted and the ultimate outcome is a poorer quality of patient care leading to unnecessary hospital admissions, re-admissions and adverse events, resulting in increased patient morbidity, mortality, and cost of care.
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To preserve vital healthcare programs, NYSNA encourages the Legislature to explore additional progressive revenue-generating ideas that have been proposed by various organizations. At the top of that list should be the extension of the temporary income tax surcharge on high-income earners. When this surcharge was enacted, policymakers believed that by the time it expired, the state and the nation would be in the midst of a robust economic recovery. Unfortunately, the recovery has been slower than expected and we now face the loss of vital and scarce revenue at the same time as federal stimulus funding is set to expire.
Extending the surcharge would provide the state enough time to implement thorough, meaningful Medicaid reform in a way that will reduce potential negative impacts on access or quality in our healthcare system. Taking almost $2.5 billion out the healthcare system in a single year will produce a financial shock wave that could close facilities, reduce staffing and harm quality. NYSNA strongly believes that it would be irresponsible for the State to cut vital programs for the most vulnerable in order to lower taxes for the most fortunate.
An additional revenue proposal is to reduce the rebate provided on the state’s stock transfer tax. Brokers and taxpayers receive a 100% rebate on the tax paid for selling or transferring shares of stocks, essentially cancelling out any revenue gains. Data shows that in 2009 the value of stock transfer rebates was $14.5 billion. Retaining just 20 percent of the rebate would have generated revenue of $2.9 billion.
The Nurses Association continues to support the creation of an excise tax on sugar-sweetened beverages. This tax will discourage the excessive consumption of unhealthy beverages that contribute to the epidemics of obesity, diabetes and heart disease that diminish quality of life and strain healthcare delivery and spending. It will promote public health by encouraging New Yorkers to make healthier choices and the added savings will be reflected in dollars, but more importantly, in healthier lives.
In conclusion, the New York State Nurses Association understands the gravity of the current economic conditions and revenue shortfalls. However, we hope you’ll agree that patient safety and the future of New York’s healthcare system cannot be sacrificed in order to close the budget gap.
We also urge policy makers to be candid with the public about the consequences of the cuts under discussion. Should the Legislature and the Governor seriously consider provisions that will result in hospital and nursing home closures, the provision of care by unqualified healthcare personnel, unsafe staffing levels and reduced government oversight, the public should be informed of these impacts so that they may judge the budget on its overall impact on New York.
As you continue your deliberations, we urge you to pass a budget that will protect the public health infrastructure and ensure access to quality healthcare for all of New York’s residents. Leadership during times of crisis doesn’t only require government to make the tough choices, but also the right choices.
Thank you for your time and consideration.
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For more information, contact the New York State Nurses Association Governmental Affairs Department at 518.782.9400, ext. 283 or by e-mail.