Parent firm of KentuckyOne Health gets conditional approval from Catholic Church to merge with San Francisco's Dignity Health

The parent firm of most Catholic-owned hospitals in Kentucky, Catholic Health Initiatives, has received conditional approval from church officials to merge with Dignity Health, a not-for-profit chain based in San Francisco.

The deal "would create the nation's largest not-for-profit hospital company by revenue," Harris Meyer and Tara Bannow report for Modern Healthcare. CHI's Kentucky facilities, operating under the name KentuckyOne Health, include Louisville's Jewish Hospital and its affiliates; St. Joseph Hospital in Lexington, London, Martin, Mount Sterling and Nicholasville; Flaget Memorial Hospital in Bardstown, Our Lady of Peace in Louisville; and Sts. Mary and Elizabeth Hospital in Louisville.

After the church's Congregation for the Doctrine of Faith deferred to local bishops, Denver Archbishop Samuel Aquila told CHI "that as long as his five moral conditions for the deal continue to be met, he had no moral objections to the merger going forward," as long as the merged chain had a recognizably Catholic name and other relatively minor conditions, Modern Healthcare reports.

"While the archbishops of Denver and San Francisco, where CHI and Dignity, respectively, are headquartered, previously had signed off on the so-called ministry alignment agreement, their approval was dependent on Vatican approval, which was uncertain," Meyer and Bannow report. "That left a cloud over the plan, initially announced in 2016, to create a combined system with 139 hospitals in 28 states with total annual revenue of nearly $30 billion."

The National Catholic Bioethics Center had given the merger "an unfavorable moral analysis . . . which added to the uncertainty about the Vatican's decision. CHI and Dignity then sought additional moral analyses from three other ethicists, who gave favorable opinions," the reporters write. "The merger still needs approval from state regulators in California, Arizona and Colorado, CHI's chief financial officer, Dean Swindle, said on an Oct. 11 call with investors."

California Attorney General Xavier Becerra is facing pressure "to ensure that the deal does not limit reproductive health services, care for LGBTQ patients, or services for low-income and under-served communities," Meyer and Barrow report. "Fifteen of Dignity's 39 hospitals are historically non-Catholic and provide services that are prohibited under Catholic doctrine, forcing the dealmakers to craft a merger model that worked around the directives." It would allow Dignity's non-Catholic hospitals to keep doing services the church considers immoral, such as tubal ligations after deliveries.

UPDATE, Nov. 23: Becerra approved the deal with conditions, including continuation of emergency services and women's health-care services at the California hospitals for 10 years. The merged firm will be CommonSpirit Health, Modern Healthcare reports.

McConnell says Senate may again target Obamacare

https://www.washingtonpost.com/politics/mcconnell-gop-may-take-another-shot-at-repealing-obamacare-after-the-midterms/2018/10/17/7a0e7c70-d23c-11e8-8c22-fa2ef74bd6d6_story.html?utm_term=.fd0ac6f59baa

UK Rural and Underserved Health Research Center symposium Nov. 12; topics include opioids, vaccines, hospitals, miners' health

The Rural and Underserved Health Research Center is holding a free half-day symposium to discuss research in a wide range of topics, including: rural opioid misuse and suicide, pneumonia-vaccine disparities, the impact of rural hospital closures on emergency services, and health-care utilization among coal miners with black lung and other respiratory diseases.

The symposium will be held at the University of Kentucky Gatton Student Center, Senate Chamber A268, from 9 a.m. to 11 a.m. Nov. 12. The event is free, but registration is required before Nov. 5. Click here to register. Click here to see the full agenda.

The RUHRC is a grant-funded program that focuses its research on access to healthcare and substance abuse treatment in underserved rural areas of the United States, including Appalachia. The research is meant to better inform health policy makers "with the ultimate goal of reducing inequities in care and improving population health in rural communities," says its website.

Ky. Rural Health Association's annual conference to be held in Bowling Green Nov. 15-16; registration prices go up Nov. 2

The 20th annual conference of the Kentucky Rural Health Association will be held in Bowling Green Nov. 15-16 at Western Kentucky University's Knicely Conference Center, 2355 Nashville Rd. Through Thursday, Nov. 1, the registration fee is $125 for KRHA members and $175 for non-members. After Nov. 1, the fees are $175 and $225, respectively. Student rates are $45 and $55, respectively. For detailed registration information, click here. For a copy the agenda and other information, click here.

E-cig conference in Louisville Dec. 10; FDA says crackdown on teen sales may impede usage by adults who want to quit smoking

Amid growing concerns that electronic cigarettes will undermine the progress made in reducing tobacco-related disease in Kentucky, the Coalition for a Smoke-Free Tomorrow will host a half-day conference Dec. 10 in Louisville to explore the latest evidence about the health effects of e-cigarettes.

Getty Images

The Foundation for a Healthy Kentucky and Kentucky Youth Advocates will also release a new focus group report that day about Kentucky youth attitudes and perceptions about e-cigs.

"E-cigarette use among youth is at now at epidemic levels, escalating dramatically since the introduction of flavored pod e-cigarettes such as Juul and copycat products," Ben Chandler, chair of the coalition and CEO of the foundation, said in a news release. "Kentucky lawmakers and health advocates need to know what the research says about these products, and how they're impacting future tobacco use and health. We'll also examine the policies that should be enacted to turn back this alarming new trajectory."

Speakers at the conference, titled "Next Generation Tobacco: The Impact of E-Cigarettes on Kentucky's Future Health," will discuss who's using e-cigarettes and other electronic nicotine delivery systems in Kentucky, and potential policies for preventing associated disease and illness.

Speakers will focus on the role of flavors in encouraging underage vaping; the extent to which e-cigarettes and other vaping devices actually help people quit smoking; what's in vaping products; whether they are a safer alternative to combustible cigarettes; and the evidence that e-cigs are a gateway to smoking for youth and young adults.

The conference will be held Monday, Dec. 10, from 8:30 a.m. to 12:15 p.m. at the foundation office, 1640 Lyndon Farm Court, in Louisville. Remote viewing sites will be announced later this month. The conference is free, but registration is required. Click here to register and to see the full agenda.

The announcement of the conference is timely.

On Oct. 12, the U.S. Food and Drug Administration sent warning letters to 21 e-cigarette companies seeking information about whether more than 40 products, including some flavored e-cig products, are being illegally marketed or are outside the agency's compliance policies, according to an agency news release.

This is the FDA's latest effort to stop the illegal sale of e-cigs to youth and decrease the "kid-friendly marketing and appeal of these products," it notes. In recent months, the agency has sent more than 1,300 warning letters and fines to retailers for illegally selling e-cigs to minors; given major e-cig makers 60 days to submit plans to address youth access and use; adjusted compliance policies; and launched a new anti-vaping advertising campaign aimed at teens called "The Real Cost."

"The FDA remains committed to the potential opportunity for e-cigarettes to help adult smokers transition away from combustible cigarettes. But we cannot allow that opportunity to come at the expense of addicting a whole new generation of kids to nicotine," Dr. Scott Gottlieb, the FDA commissioner, said in the release.

He added, "We’ll take forceful steps to stem the youth use, even if our actions have the unwelcome effect of impeding some opportunities for adults. These are the hard tradeoffs we now need to make."

Flu season is here, and Kentucky has already seen one death from it; health officials urge all 6 months and older to get a shot

By Melissa Patrick
Kentucky Health News

The 2018-19 flu season has barely started, but Kentucky has already reported its first flu-related death -- in Lexington, according to the Lexington-Fayette County Health Department. The flu killed 325 people in Kentucky in the last flu season.

Flu is a very contagious disease caused by the influenza virus that spreads from person to person. Symptoms include fever, headache, cough, sore throat, runny nose, sneezing and body aches.

An antiviral drug can shorten the course of the illness or reduce its severity if given within two days of a person getting the flu, but there is no real treatment for the disease, and that's why health officials encourage everyone six months and older to get a flu shot.

"There's no treatment for the flu," Dr. Ryan Stanton, a Lexington emergency-room physician, told WKYT-TV. "Our only fight against this is prevention."

KHN Editor Al Cross's bandage after
his flu shot. (Photo by Patti Cross)

Concern that the state will experience another flu epidemic like last season has prompted a statewide "Focus on Flu" campaign to encourage Kentuckians to get their flu shot. The campaign is being led by doctors, health agencies and the Foundation for a Healthy Kentucky. Their message: "Get your shot! Consult your doc! Stop the spread!"

And it's a message for sharing. Kentucky ranks 33rd in the nation for the number of people who get a flu shot, and at the campaign's kick-off rally in September, it was reported that only 40 percent of Kentuckians got a flu shot last flu season.

And while a flu shot won't guarantee that a person won't get infected, the U.S. Centers for Disease Control and Prevention says it will reduce the risk of infection by 40 to 60 percent, and it has been shown to reduce the severity of illness in people who get vaccinated but still get sick.

Experts also recommend that people get the shot early, because it takes about two weeks after the vaccination for the recipient to develop immunity.

Contrary to a pervasive myth, the flu vaccine cannot give you the flu.

The CDC says "flu vaccines cannot cause flu illness" because the vaccine is made from flu viruses that have been "inactivated" or "killed" and thus are not infectious, or from a single gene from a flu virus, as opposed to the full virus, which allows a person to produce an immune response without getting the infection.

The CDC recommends that everyone over six months of age get a flu vaccination every year, and especially people who may be at higher risk for complications or negative consequences. They include:

• Children age six months through 59 months;
• Women who are or will be pregnant during the flu season;
• Persons 50 years of age or older;
• Persons with extreme obesity (body-mass index of 40 or greater);
• Persons aged six months and older with chronic health problems;
• Residents of nursing homes and other long-term care facilities;
• Household contacts and caregivers of children younger than 5 and adults 50 and older.
• Household contacts and caregivers or people who live with a person at high-risk for complications from the flu; and
• Health care workers, including physicians, nurses, medical emergency-response workers, employees of nursing home and long-term care facilities who have contact with patients or residents, and students in these professions who will have contact with patients.

And don't forget to use common-sense practices: wash your hands frequently, cover your mouth when you cough or sneeze and stay home when you are sick to stop the spread of infection.

If you're looking for a place to get your flu shot, the CDC offers an interactive "flu vaccine finder" that allows you to type in your zip-code to find nearby locations that offer flu shots. Local health departments also offer the vaccine.

Providers didn't give reason for prescribing opioids 1/3 of the time; study says better documentation could decrease prescribing

An analysis of medical records from 2006 to 2015 found that doctors didn't record a diagnosis for opioid prescriptions almost one-third of the time.

"The findings help support criticism by the Centers for Disease Control and Prevention, the Food and Drug Administration and others that say inappropriate prescribing practices have helped drive the opioid crisis," Maggie Fox reports for NBC News.

Nearly 50,000 Americans died from opioids in 2017, 1,565 of them in Kentucky.

CDC photo

The analysis, published in the Annals of Internal Medicine, used data from the National Ambulatory Medical Care Survey, an annual survey of doctor-office visits.

Because providers can enter up to three diagnosis codes per visit, the researchers limited their sample to visits with two or fewer codes to remove this as a possible reason for not listing pain as a diagnosis.

The study found that opioids were prescribed in nearly 32,000 visits, for cancer-related pain 5 percent of the time and for a non-cancer pain 66 percent of the time.

"No pain diagnosis was recorded at the remaining 28.5 percent of visits in which an opioid was prescribed," says the report. It adds later, "At visits with no pain diagnosis recorded, the most common diagnoses were hypertension, hyperlipidemia [high cholesterol], opioid dependence and ‘other follow-up examination'."

Kentucky has aggressively worked to crack down on prescription-drug abuse, including passing a law in 2017 that limits painkillers to a three-day supply for acute pain, in keeping with the CDC's recommendations. However, the law has a long list of exemptions, and allows a prescriber to override it by documenting a justification.

"Transparently and accurately documenting the justification for opioid therapy is essential to ensure appropriate, safe prescribing; yet, providers currently fall far short of this, particularly when renewing prescriptions," the researchers conclude. "Requiring more robust documentation to show the clinical necessity of opioids—which many insurers already do for novel, costly drugs—could prompt providers to more carefully consider the need for opioids while facilitating efforts to identify inappropriate prescribing."

U of L gets $16.4 million from National Institutes of Health to study impacts of the environment on diabetes and obesity

The University of Louisville has been awarded $16.4 million to study how the environment impacts diabetes and obesity, U of L announced.

"Officials said research will be conducted on how air pollution could be connected to diabetes, and whether the dietary supplement carnosine can protect people from air pollution," reports Lisa Gillespie of WFPL.

Aruni Bhatnagar, director of the U of L Diabetes and Obesity Center, told Gillespie that the funding will also be used to explore diabetes and obesity as it relates to cardiovascular issues.

“Diabetes and obesity are the leading cause of public health problems within the country as well as within the state,” Bhatnagar told Gillespie. “Heart disease is one of the main consequences of diabetes and obesity. In fact, people who have diabetes, about 70 percent of them die from heart disease.”

The National Institutes of Health grant will also fund research around the effects of pollution on stem cell health; how exercise can reduce inflammation; and how the heart talks to blood vessels to increase blood flow during exercise, the university says.

Free webinar Nov. 28 on why Ky. cities and counties can't pass local laws around the distribution, sale and regulation of tobacco

The Foundation for a Healthy Kentucky is offering a free webinar about how state laws prevent local governments from passing tobacco-control ordinances and other health policies in Kentucky.

The laws "pre-empt" local regulations on distribution, sale and regulation of tobacco products, so if a city or county in Kentucky wants to pass an ordinance to raise the legal age to purchase tobacco products, or ban tobacco flavors in electronic cigarettes that appeal to youth, they can't.

Presenters in the webinar will share their experiences with teh issue and discuss advocacy strategies for countering and repealing pre-emption laws.

They include Tonya Chang, vice president for advocacy with the American Heart Association Great Rivers Affiliate; Ellen J. Hahn, professor, University of Kentucky Colleges of Nursing and Public Health; Traci Kennedy, consultant to Americans for Nonsmokers' Rights; and Mark Pertschuk, director of Grassroots Change: Connecting for Better Health.

The free one-hour webinar is part of the foundation's Health for a Change training series. It will be held Wednesday, Nov. 28 from 1 p.m. to 2 p.m. Click here to register.

Louisville psychiatrist writes book about landmark research that gets to root of why people struggle in their relationships

Nov. 18, 2018: Story updated to reflect Living on Automatic: How Emotional Conditioning Shapes Our Lives and Relationsips was chosen by American Book Fest as a finalist for the "2018 Best Book Award" for best new non-fiction .

By Melissa Patrick
Kentucky Health News

In a world inundated with interpersonal conflicts, a Kentucky psychiatrist has written a groundbreaking new book that explains what lies at the root of these conflicts and offers a way to resolve them.

"It's a book that talks about why the things that go wrong in our relationships go wrong, and why we live on automatic pilot and do things that we sometimes don't even want to do, but we repeat them over and over again and we wish we could stop," Dr. Christine B.L. Adams, one of the book's authors, said in a telephone interview.

The book, Living on Automatic: How Emotional Conditioning Shapes Our Lives and Relationships, is a collaborative effort between Adams, a child psychiatrist in Louisville, and the late Dr. Homer B. Martin, her colleague and mentor. Adams said their landmark research around emotional conditioning is based on 80 combined years of psychotherapy with thousands of patients. It was recently chosen by American Book Fest as a finalist for the "2018 Best Book Award" for best new non-fiction.

The authors write that people are emotionally conditioned within the first two to three years of life by their parents or caretakers to fall into one of two roles that form the basis of their personalities.

The two roles are called omnipotent and impotent. An omnipotent is conditioned to please and do for others; an impotent is conditioned to need constant emotional care and attention from others. Each role is a matter of degree, the authors say; people fall on a continuum from mild to severe for each of these conditioned roles.

The result of this emotional conditioning, Adams says, is that people tend to seek relationships that meet their own needs, rather than relationships that recognize each other as individuals.

But this isn't working, she said, pointing to how interpersonal conflicts have resulted in such high rates of divorce and substance abuse and increasing conflicts between parents and their children.

"So this says to me that the way we've been doing it has not been very successful and perhaps there is a better way," Adams said.

That way, she says, is for people to re-learn how to interact with each other in ways that promote better relationships. She calls it deconditioning, and explains it in the final chapters of the book.

"What you learn to adopt when you try to shed your conditioning is a standard of reasonableness rather than a standard of automatic conditioned responding," she said. "You have to learn a technique of evaluating yourself and the other person simultaneously in every exchange you have with them."

She added that this technique helps a person determine what is called for in each situation.

"In this way you don't automatically respond just to the role of the other person," she said. "You respond according to what each person needs for the particular situation at that particular time."

Adams said people who have gone through this process "have much better lives, are able to manage their lives better and have better relationships," and when one person goes through the process it typically has a "ripple effect" throughout a family and others who are close to them.

Beyond romantic relationships, Adams said the book also has applications for young parents to help them raise "more well-balanced" children, as well as help for agencies that work with children.

She said the book is written for a general audience, in hopes of bringing awareness to this new concept of emotional conditioning, and how this causes us to act on automatic pilot most of the time when it comes to our relationships.

"This is a landmark study of what really happens in relationships," she said. "And when you impart information to people that they've not known before, then a lot of people start thinking about it in new ways and will apply it to themselves and their family and their friends."

Look beyond premium costs when choosing a Medicare plan; Medicare Advantage may not be an advantage for you

By Trudy Lieberman, Rural Health News Service

Making decisions about Medicare coverage has never been easy. Over the years the task has become more complicated as Congress has moved to privatize the system.

Open enrollment, the time for evaluating your coverage and making changes if you can, opens Oct. 15 and runs through Dec. 7 this year. This is the first of two columns that address decisions people about to become eligible for Medicare and those already on the program will have to make.

While some 57 million people are still in traditional Medicare, which remains a social insurance program, the number of beneficiaries in privatized Medicare known as Medicare Advantage has grown steadily. Today one-third of all beneficiaries have joined private plans, many of them responding to sales pitches - sometimes questionable ones - from insurance companies that now regard their Medicare Advantage business as a major profit center.

With a Medicare Advantage plan, generous payments from the federal government to private insurers allow them to provide a person’s Medicare benefits along with some extras like eyeglasses, limited dental care, and gym memberships. The government payments have been so rich they’ve also allowed the plans to entice people to join by offering coverage with no monthly premium or a very low one.

So the first basic choice is whether to select traditional Medicare -- and buy a supplement to fill in what Medicare doesn’t pay -- or to select a Medicare Advantage plan.

Increasingly, though, some people may not have a choice. More employers who fund part of their retirees’ health insurance are automatically enrolling their workers about to retire in Medicare Advantage plans, and those workers may not understand what they are getting, said Tricia Neuman, a senior vice president of the Kaiser Family Foundation: “Employers may see this as an attractive way to shift some of the risk to employees.”

A few years ago, I met a retiree of a computer firm in California who had developed Parkinson’s disease and was seeking help from the state’s insurance counseling program to switch out of the employer’s retiree Medicare Advantage plan. He was having trouble seeing the specialists he needed to treat his disease.

Counselors told him he had few options. He could easily drop his Medicare Advantage plan and return to traditional Medicare. But he was no longer eligible to buy a Medigap policy, which he sorely needed.

California, like almost every other state, says insurers offering Medigap policies may scrutinize senior applicants’ health status once those seniors have passed their initial eligibility period. That period is generally the first six months after they sign up for Medicare Part B, which pays for physician services and hospital outpatient care. After that, if you have a preexisting condition, you’re out of luck.

Only New York, Connecticut, Massachusetts, and Maine allow seniors to buy a Medigap policy anytime. A few other states allow seniors to buy them under certain conditions - like losing retiree coverage. Seniors living outside those states, though, could be making an irrevocable decision by choosing a Medicare Advantage plan or allowing themselves to be placed in one automatically.

Yet the allure of no monthly premium or a cheaper premium than a Medigap policy would require draws seniors to Medicare Advantage plans. A cheaper premium or no premium sounds good when you’re well, but what happens when you’re sick? That’s when many seniors find they want to go back to traditional Medicare.

“Premiums are not a good way to choose a plan. It’s important to look beyond the premium,” Neuman advises.

Still, not much is known about how seniors in Medicare Advantage plans fare when they have a really serious illness. But in late September the Office of the Inspector General reported that insurers offering Medicare Advantage plans may be inappropriately denying services to seniors and called on Medicare to step up its oversight of those plans.

The Office of the Inspector General found that Medicare Advantage plans overturned 75 percent of their denials between 2014 and 2016, raising questions about why seniors were denied in the first place.

“The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided,” the report noted. “This is especially concerning because beneficiaries and providers rarely used the appeals process.” Seniors may be denied services but never register any complaints.

As with all insurance, you make a trade-off. Pay less upfront and more when you get sick, or minimize your risk by paying more in premiums to have better coverage when illness strikes. That is the great-unknown seniors must consider.

Traditional Medicare plus a good Medigap can become your best friends if you have a hospitalization for a serious illness as I had when an infection came out of the blue and kept me in the hospital for four months earlier this year. For doctor, hospital, and rehabilitation charges that totaled some $3.5 million, we paid only about $2,500 out of pocket.

My next column will address finding a good drug benefit.

What experience have you had with Medigap policies or Medicare Advantage plans? Write to Trudy at trudy.lieberman@gmail.com.

Need for improved staffing in nursing homes and hospitals was among timely topics at annual Health Watch USA conference

By Melissa Patrick
Kentucky Health News

Several speakers at the Oct. 4 Health Watch USA Healthcare Transparency and Patient Safety Conference in Lexington talked about the importance of adequate staffing in nursing homes and hospitals to maintain and improve safety for patients and staff.

Sherry Culp of the nonprofit Nursing Home Ombudsman Agency of the Bluegrass said that while regulations issued in 2016 by the Centers for Medicare and Medicaid Services have offered some positive changes, such as requirements for improved training and "appropriate competencies and skills," and better provisions for planning of care, it didn't do enough with staffing.

"The final rule really fell short on nursing staffing standards," she said. "We wanted there to be registered nurses in the building 24 hours a day. . . . We know that an RN level of nursing is the level that has the competence to deal with some of the significant changes in conditions that occur in this vulnerable population."

Culp said the rules only require an RN to be in the building eight hours a day, and that person is often "locked up in an office doing paperwork," while 90 percent of the care is provided by nurse aides, who have less than 100 hours of vocational training. Her agency monitors living conditions at nursing homes and informs residents of their legal rights.

Woodcrest Nursing and Rehabilitation Center in Elsmere has
a one-star rating. In 2016 a resident fell down the stairs in his
motorized wheelchair, died and went undiscovered for
nine hours. (Herald -Leader photo by Marcus Dorsey)

She said the agency gets calls from overwhelmed aides who tell her they have been put into impossible situations to care for as many as 40 people with little orientation and no help. "I think a lot of nurse aides are just thrown to the wolves," Culp said.

As part of a three-part, in-depth report on the dismal state of Kentucky's nursing homes, John Cheves of the Lexington Herald-Leader reports about the staffing issues in Kentucky's nursing homes, noting that collectively Kentucky's nursing homes rank as some of the worst in the country.

As of Aug. 7, he reported that Kentucky had 52 "one-star" nursing homes (18 percent of the state total), which are considered to be "much below average" and 71 "two-star" homes (25 percent), which are "below average." These ratings come from CMS's five-star rating system, which looks at a facility's staffing, health inspections and quality of resident care.

Hospitals have staffing issues, too

Staffing issues are also an issue in hospitals, said Christine Pontus, associate director of health and safety for the Massachusetts Nurses Association.

Pontus pointed out that registered nurses are vital to the care of patients because they are the front line person to recognize and react to a patient's ever-changing health status. She called this process "surveillance" and said that basically, "That's what nurses do."

She shared research to support the importance of nursing surveillance, which found that "greater nurse surveillance capacity was significantly associated with better quality of care and fewer adverse events," and the ability of nurses to provide appropriate surveillance is, among other things, largely dependent on adequate staffing.

Culp said RNs are needed 24 hours a day in nursing homes because it is imperative that someone with appropriate training be able to to determine if further care is needed when residents fall and hit their head. She said some of these fall victims have injuries that go unnoticed, "sometimes ever, or until their death or weeks later."

One study of staffing in hospitals, found that RNs who work in an environment that supports their physical and emotional safety are more able to provide better surveillance, which ultimately leads to improved patient outcomes, more positive patient experiences and higher RN engagement rates.

"National, peer reviewed studies show higher patient assignments are associated with more patient deaths, complications, medication errors and readmissions," Culp said.

Pontus noted that while Medicare requires "adequate" numbers of nurses at all levels, it doesn't define the term or who determines the numbers. Similarly, she said the Joint Commission that accredits hospitals calls for the "number, competency and skill mix of staff in relation to the provision of needed care and treatment," but does not clearly define or offer a formula to determine this mix.

"These ambiguous statements allow health care facilities to continue to operate at or below minimum [staffing] levels," she said. "Something is not working. Regardless of all the regulations and the Joint Commission, it's not working and we need to do something."

Jonathan Rosen, safety and health consultant for AJ Rosen & Associates LLC, cited another study that looked at nurse staffing and hospital deaths: "We estimate that the risk of death increased by 2 percent for each below-target shift and 4 percent for each high-turnover shift to which a patient was exposed."

So far, California is the only state to pass a nurse-to-patient ratio law. Rosen said a study found that since the requirements took effect, nurses' occupational injuries have dropped one-third.