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Lokvani Talks To Anu Puri

Ranjani Saigal

Anu Puri has over sixteen years of experience in the health care finance and policy arena including in legislative, regulatory, financial and policy analysis. Her areas of specialization include payment and delivery system reform; healthcare cost and performance trends; impact modeling of reimbursement policy and quality based payment reform initiatives. She assists hospitals in strategy development on a variety of health policy issues.  Ms. Puri earned her M.D. in India and her Masters in Public Health from Harvard University.

Could you describe your journey from Physician to Health Care Policy? 

I have had the joy of living on three continents, having completed most of my schooling in Africa, followed by medical school in India. And though it wasn’t a specific area of focus for me during those years, I was intrigued by the differing philosophies and approaches to both the provision and financing of healthcare in these places. After migrating to the United States about 20 years ago, I seized upon the chance to learn about how exactly the U.S. health care system works, so I “went back to school” and the rest, as they say, is history.

Could you tell us a little about your work? 

I’ve spent the past decade and a half of my professional life on the policy side of healthcare—analyzing financial, operational and other implications of legislative and regulatory issues at both the state and federal level; tracking cost and performance trends and understanding payment and delivery system reform efforts. As most of us who have had any sort of encounter with the healthcare system would attest, it is certainly, and often needlessly, complicated. That contributes to making my work very interesting but also, admittedly, occasionally exhausting!

You are a big advocate for voting no on Question 1. Could you tell us a little about Question one and why we should vote no? 

On November 6th Massachusetts voters will decide the fate of three ballot referendums, of which Question 1 directly impacts the healthcare system, and by extension, every single one of us. Basically, Question 1 would cap the maximum number of patients a registered nurse can be assigned at a given time. On the face of it, this may sound like a fine idea— we all have the highest respect for nurses, and appreciate the work they do. But it is critical to understand the details and broader implications of Question 1 before deciding how to vote on it.

If Question 1 passes, nurse-to-patient ratios would apply in all hospitals (from large Boston hospitals like Mass General Hospital to community hospitals like Emerson Hospital to Children’s Hospital to Psychiatric hospitals etc.). They would apply to all units (from the Emergency Department to the Medical-Surgical Unit to the Operating Room to the Maternity Unit etc.).  And the staffing ratios would apply at all times, meaning during all breaks, meal times etc. Local factors like nurse training, experience, technology, patient acuity, the presence of other members of the care team—none of these are factored in. For a given type of unit, the ratios would be identical in the daytime and at night, when most patients are asleep. It effectively means no flexibility.

And there are no exceptions--the ratios will always be in effect, even during times of crisis like major auto accidents or natural disasters, such as hurricanes and blizzards. Failure to comply could result in hefty penalties of $25,000 per occurrence per day.

The single most worrisome part of Question 1 to me is that it specifies 4 different ratios in the Emergency Department (from 1:1 for critical patients; 1:2 for critical stable patients; 1:3 for urgent stable patient and 1:5 for non-urgent stable patients). How this could even be implemented in the ED, where patients’ conditions change by the minute: would staffing have to be reconfigured by the minute?

Take the analogy of another life-saving situation, firefighting. Imagine a team of firefighters fighting a house fire, and a spark ignites the home next door. Wouldn’t we want the firefighting team to use their professional experience and judgement to redeploy some of the firefighters over to the house next door while awaiting backup? Or would we prefer a state mandate requiring 4 firefighters to fight every house fire at all times, thus putting them in a position where they’d break the law if they redeploy, and incur hefty penalties? These are professionals, entrusted with saving lives. As are members of the health care team--we should not tie their hands by treating nurses and patients as mere numbers in an equation.

The broader consequences of Question 1 for our healthcare system and communities are obvious: longer ED wait times, delays in life-saving services, increased transfers to other hospitals, decreased access to care (as hospital units, and perhaps entire hospitals, close) and increased healthcare costs (the estimated cost is $1.3 billion to implement in year 1, $900 million annually thereafter) which will mean higher premiums, deductibles and taxes.

While no-one is suggesting that staffing at hospitals is always perfect, this is NOT the solution. Especially since there is no research evidence, including from California, the only state with this requirement, that rigid at-all -times nurse staffing ratios improve patient outcomes.

I urge readers to carefully consider all these facts and vote NO on Question 1.

The ad says 86% of Nurses are voting yes on question 1. Could you clarify? 

That ad is very misleading and untrue. It is taken from an opinion-based survey paid for by the Massachusetts Nurses Association (MNA), the nurses’ union behind Ballot Question 1. There were only 302 survey responses and the survey oversampled the views of union members.

It is important to understand that the MNA only has 23,000 members, compared to approximately 130,000 Registered Nurses in Massachusetts. More than 30 healthcare organizations oppose Question #1, including nursing organizations such as the American Nurses Association, Organization of Nurse Leaders, Academy of Medical-Surgical Nurses and the Emergency Nurses Association. All these organizations are rightly concerned that our healthcare system will be in serious jeopardy if Question 1 passes.

Any message for our viewers? 

Please remember to vote. Elections have consequences.

Where can we get more information about this topic? 

Please visit the website of the Coalition to Protect Patient Safety at www.ProtectPatientSafety.com for additional information or visit their Facebook page at www.facebook.com/ProtectPatientSafety

For people who want to learn more about Health Care Policy, where do we you suggest we start?

That is a great question! There is so much out there, but very few places where the information is presented in an easily accessible but fairly comprehensive fashion. I think www.PatientCareLink.org is a good place with key information for patients, families and other stakeholders. For more detailed data on state issues and trends, the state’s Health Policy Commission is a good place to start.

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