Nurse Patient Ratio Federal Law Peer Reviewed and Scholarly Articles
John M. Welton, PhD, RN
Abstract
Proponents of mandatory, inpatient nurse-to-patient staffing ratios accept lobbied state legislatures and the United states of america Congress to enact laws to amend overall working weather in hospitals. Proposed minimum, nurse-to-patient staffing ratios, such as those enacted by California, are intended to address a growing concern that patients are beingness harmed by inadequate staffing related to increasing severity of disease and complexity of care. However, mandatory ratios, if imposed nationally, may result in increased overall costs of care with no guarantees for improvement in quality or positive outcomes of hospitalization. The costs associated with the additional registered nurses that volition exist needed for the college, mandated ratios will non be offset by boosted payments to hospitals, resulting in mandates that will be unfunded. An culling approach would be to provide a marketplace-based incentive to hospitals to optimize nurse staffing levels by unbundling nursing intendance from electric current room and board charges, billing for nursing care time (intensity) for private patients, and adjusting hospital payments for optimum nursing care. The revenue lawmaking information, used to charge for inpatient nursing care, could exist used to benchmark and evaluate inpatient nursing care operation by case mix across hospitals. A nursing intensity adjustment to hospital payment, such as that described above, has already been endorsed by national nursing organizations. Efforts to implement this model nationwide inside the next few years take already been initiated. This article volition argue for the benefits of implementing a nursing intensity adjustment for nursing care by briefly reviewing the process past which nurses lost their economic independence; describing the gap betwixt the supply and demand for registered nurses; presenting the arguments for and confronting mandatory, nurse-to-patient staffing ratios; offer a different approach for increasing the number of registered nurses at the bedside, namely nursing intensity billing; proposing sources of funding to pay for nursing intensity billing; and identifying limitations of nursing intensity billing.
Citation: Welton, J., (September 30, 2007) "Mandatory Infirmary Nurse to Patient Staffing Ratios: Time to Accept a Different Arroyo"OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 3, Manuscript 1.
DOI: ten.3912/OJIN.Vol12No03Man01
https://doi.org/x.3912/OJIN.Vol12No03Man01
Fundamental words: nurse staffing; nursing minimum data set; diagnosis related grouping; cost of care; nursing intensity; health services research; nurse-to-patient staffing ratio; nursing workforce.
In the by several years, there has been a growing need for more than registered nurses in hospitals due to rising acuity of patients and shorter lengths of stay. The safety and quality of patient care is directly related to the size and feel of the nursing workforce. Inpatient working weather have deteriorated in some facilities because hospitals have not kept up with the rise demand for nurses. This situation has motivated some land legislatures to enact or consider regulatory measures to assure acceptable staffing. These regulatory measures assign some minimum level of staffing that all hospitals must meet regardless of the types and severity of patients.
This article provides an alternative to mandatory, nurse-to-patient staffing ratios. The master weakness of the regulatory approach is that hospitals are required to increase the number of registered nurses without receiving increased reimbursement for patient care. The primary weakness of the regulatory approach is that hospitals are required to increase the number of registered nurses without receiving increased reimbursement for patient care. In response, hospitals decrease the number of other staff, such every bit unlicensed assistive personnel and business firm keepers, to recoup for the loss in acquirement. This has put boosted burdens on registered nurses every bit they are and so forced to assume non-nursing care tasks (Mitchell, 2007). An alternative method that has the potential to improve inpatient nurse staffing and improve payment to hospitals would be to direct link the costs and billing for inpatient nursing care with hospital reimbursement.
This article volition explore an approach that would link cost and billing with reimbursement by separating nursing intendance from daily room and board charges and billing for nursing care based on the actual hours of intendance delivered to patients. The method is an adaptation of the original work by Thompson and colleagues who argued for a nursing intensity adjustment for the Diagnosis Related Group (DRG)-based prospective payments to hospitals, which were implemented in 1983 (Thompson, Averill, & Fetter, 1979; Thompson & Diers, 1991). Incorporating nursing variable costs direct into the billing and reimbursement system could align payment with costs and also provide a new source of nursing data based within the national billing organisation. These data could provide a method to compare nursing care across different hospitals and allow reporting of nursing intendance intensity trends for individual patients within each DRG, which in turn could provide a footing for identifying which hospitals are performing well and which are not. Ultimately this could pb to a national consensus equally to how much work nurses can perform safely for individual patients based on patient diagnosis, severity of illness, and other measurable characteristics, and provide an estimation of the economic value of nursing care and a measure of its worth.
This article will discuss the benefits of implementing a nursing intensity adjustment for nursing care past: reviewing the process by which nurses lost their economic independence; describing the gap between the supply and demand for registered nurses; presenting the arguments for and confronting mandatory nurse-to-patient staffing ratios; offer a different approach for increasing the number of registered nurses at the bedside, namely nursing intensity billing; proposing sources of funding to pay for nursing intensity billing; and identifying limitations of nursing intensity billing.
How Nurses Lost Their Economic Independence
At the showtime of modern nursing history, Nightingale educated nurses to take on more than complex nursing duties and responsibilities in the care of the sick. Although this grooming took identify in hospitals, Nightingale was really preparing these early nurses for contained practice in the dwelling. Until the 1920'south, well-nigh all hospital functions were carried out by unpaid, student nurses under the watchful eye of the nursing superintendent while graduate (private duty) nurses provided care in the habitation. The modernistic hospital was born soon after the Offset Globe War with the introduction of a myriad of new technologies, such every bit aseptic surgery, anesthesia, modern pharmaceuticals, x-rays, and laboratories to mensurate biological functions. Inside a decade, most acute patient care had moved from the domicile to the hospital; and the private duty nurses who had followed their patients into the hospital were somewhen captivated as employees of the infirmary, losing their independence and entrepreneurial practice (Reverby, 1987). They lost their power to set up staffing standards; to establish their salary, since they were no longer paid straight by the family or patients for their services (Welton & Harris, 2007); and to demonstrate their value equally registered nurses. The other negative outcome of this modify was the incorporation of hospital nursing care into the room and board accuse, both as an accounting for the total price of nursing care and equally the method used to charge patients for their intendance (Thompson & Diers, 1991).
Traditionally hospitals had used unpaid students to meet most of their staffing needs. With the influx of more patients coming into hospitals for their nursing care, the hospitals were challenged to contain this new cost of registered nurses into their accounting systems. Thompson and Diers (1991) relate:
Most hospitals were charging less than their [nursing] costs for room and board. Many theories have been advanced for this practise, the most likely one being that patients could compare the costs of a infirmary 'room' with that of a hotel, not realizing the 'room and board' included many services non offered by hotels. The exercise of costing and defining hospital service by this misnamed 'room and board' eventually proved to be self-defeating, and can be interpreted as a deliberately confusing practice. That nursing was cached along with brooms, breakfast, and the building mortgage had consequences not only for the visibility of nursing's service, simply as well for the wage structures as hospitals increasingly began to compete on room and board rates, using oligoposonistic practices to artificially constrain nursing salaries. (p. 152)
A second alter in nursing practice occurred just subsequently the 2d World State of war, every bit new technologies...were being introduced into the hospital environment. A 2nd modify in nursing practice occurred just after the Second World War, every bit new technologies such every bit ventilators, cardiac monitors, and powerful intravenous drugs, were being introduced into the infirmary surround. The sicker patients who required these interventions dramatically increased the intensity of nursing care also as the level of training and expertise needed to treat these more complex patients. It became more than hard to know how to staff the commonly used, large wards of that era as nursing intensity began to fluctuate more than significantly with each new admission. Shortly the mod cardiac and intensive care units were born, partly out of necessity to manage both nurse staffing and expertise (Cadmus, 1954; Cadmus, 1980). At present at that place were 2 types of units, the traditional "flooring" and the newer, "intensive care" units (ICUs). Although the charges for each blazon of unit differed, both remained fixed charges for each patient inside that type of unit. Even so, these charges did not reverberate the variability in nursing care required for individual patients on either of these types of units. For example, a 'stable,' ventilated patient in the ICU could rapidly exist weaned and sent to the floor to make room for an unstable and critically ill patient waiting in the emergency department. Sometimes such a now unventilated patient on the floor would actually crave college intensity nursing care than was needed in the ICU to maintain airway patency and oxygenation status. This increased intendance imposed a much higher nurse staffing need on the medical or surgical flooring; yet there was, and still is, no way for the hospital to nib for this extra nursing care required.
A third modify that influenced nursing care, namely the introduction of managed care in the early 1990's, moved a substantial number of patients requiring less intense care out of the hospital and into ambulatory or outpatient settings, thus decreasing the average length of patient stay. Graf, Millar, Feilteau, Coakley, and Erickson (2003) and as well Unruh and Fottler (2006) have reported that lengths of hospital stay have decreased from a typically 7 to 8 day stay in the 1980s to a current iv to v day stay, resulting in higher patient turnover every bit well as overall severity of illness. This "sicker and quicker," inpatient surround has atomic number 82 to a significant increase in both the intensity of nursing care for each patient and the demand for more nurses, requiring a college ratio of nurses to patients. Betwixt 1980 and 2004 the average number of registered nursing-care hours per patient day has more than doubled from iv.7 hours per day to x.7 hours, equally noted in Effigy 1. This trend illustrates the chop-chop changing, inpatient intendance environment and the essential need to measure how well hospital-based nursing care is meeting the needs of today's patients. When hospitals do not increase nurse staffing to adequate levels, patient complications tin can occur and patient care can deteriorate to the signal that hospitals fail economically. When hospitals do not increase nurse staffing to acceptable levels, patient complications can occur and patient care can deteriorate to the point that hospitals fail economically. This failure occurs equally a result of the high cost of treating those patient complications that could have been prevented by having an adequate number of nurses, but which will occur when an adequate number of nurses per shift are non provided. Assessing the toll of these preventable complications tin help to demonstrate the economic value of the registered nurse (RN), who is prepared to forbid these complications. Nonetheless the gap between the supply and the demand for RNs continues to grow.
| Effigy one. Changes in Inpatient Length of Stay and RN Nursing Hours per Patient Mean solar day |
 |
Data for use in this figure were derived from the American Infirmary Clan (2005) annual survey and the U.S. DHHS National Sample Survey of Registered Nurses 2004 (HRSA, n.d.).
The Gap Between Supply and Demand for Registered Nurses
Today we are experiencing a gap between patient demand and the nursing intendance available to meet patient needs. Today we are experiencing a gap between patient need and the nursing intendance available to meet patient needs. This gap occurs because patients at present remain in the hospital only as long as they are acutely ill and conspicuously in need of nursing care. One time these very acute intendance needs are met, patients are discharged. Before long other patients, likely with even higher vigil needs, will exist admitted to these beds previously occupied by the recently discharged patients. A greater proportion of beds volition and so be filled by patients with very high vigil needs. Unfortunately, hospitals have not kept up with the need to provide more nurses to care for this increased number of patients requiring college acuity care. This gap has led to discussions regarding the quality and safety of hospital nursing care currently provided. The increasing intensity of care, due to a greater number of invasive procedures, more powerful medications, and a growing number of patients with chronic acute illness, has markedly increased the intensity of nursing care needed. In improver, a growing elderly patient population with higher needs for help with activities of daily living has also contributed to the supply/need gap for inpatient nursing care.
In the by few years, diverse state legislatures have attempted to close this gap by setting standards for college levels of nurse staffing on patient intendance units. California legislators, at the behest of the California Nurses Association (not to be confused with the ANA/California, which is the constituent member of the American Nurses Clan [ANA]), passed a law to crave hospitals to staff then as to come across minimum nurse-to-patient staffing ratios on the diverse hospital units (Seago, 2002; Seago, Spetz, Coffman, Rosenoff, & O'Neil, 2003; Spetz, 2001). Several other states (Washington, Colorado, Texas, and New Bailiwick of jersey) have recently introduced new legislation to meet the demand for more than nurses; and in the Massachusetts state house ii competing bills addressed nurse staffing. One beak, strongly supported by nursing labor groups, advocated for mandatory nurse-to-patient staffing ratios; the other bill, supported by the Massachusetts Hospital Clan and the Massachusetts Arrangement of Nurse Executives, advocated for the avoidance of staffing ratios past closer monitoring of nurse staffing trends and funding main nursing education (Curtin, Gall, & Vigue, 2006). A proposed nib in the state of Washington would crave the adoption of safe staffing plans rather than specific nurse-to-patient staffing ratios (Byrd, 2007). In that location have also been several attempts in the last few years in both the United States (US) Firm and Senate to accost and enact hospital nurse staffing laws.
These legislative efforts raise a number of issues. First, ...there has been little evidence that specific nurse-to-patient staffing ratios improve safety or quality. there has been piddling evidence that specific nurse-to-patient staffing ratios amend condom or quality. For example, a study of California hospitals earlier and afterwards the imposition of mandatory ratios demonstrated an increase in costs but no improvement in quality of care (Donaldson, Bolton, Aydin, Brown, Elashoff, & Sandhu, 2005). Legislatively mandated nurse-to-patient staffing ratios also create an unfunded mandate considering the current payment system treats nursing intendance every bit a stock-still cost that is the same for all patients regardless of the bodily amount of nursing care delivered to an individual patient (Welton, 2007; Welton & Harris, 2007). This cost associated with hiring more RNs who will be needed for the higher, mandated ratios volition non be offset by additional payment to hospitals. This legislation would require, but not fund, this new mandate. Arguments both for and against mandatory nurse-to-patient staffing ratios have now been put forth and will exist discussed below.
The Argument For and Against Mandatory Nurse-to-Patient Staffing Ratios
Proponents of mandatory, nurse-to-patient staffing ratios bespeak to research indicating an association between nurse workload and patient mortality and morbidity. Two studies in particular have been used to support development of state and federal laws. The first, a written report of 799 hospitals in 11 states, found a college prevalence of infections, such every bit pneumonia and urinary tract infections, failure to rescue, and stupor or cardiac abort when the nurses' workload was high (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). A second widely acknowledged study investigated the human relationship between staffing levels at 168 Pennsylvania hospitals in 1999 and bloodshed rates of selected surgical patients. The investigators reported that for each additional patient a nurse was assigned, there was a vii percent increment in the likelihood of dying for a patient under that nurse's care (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). These findings have been the primary arguments for setting specific, nurse-to-patient staffing ratios.
At that place are several weaknesses in these studies, as well as other studies, evaluating the relationship between nursing workload and patient care quality. The nurse-to-patient staffing ratios used by both Needleman'due south team and Aiken'southward team are hospital averages, non individual, nursing unit of measurement-level measures. There is no footing in these two studies for generalizing to any particular nursing unit or individual patient. Furthermore, the measure of patient death in the select surgical patients may not be a direct measure of general, inpatient, nursing quality. Information technology is equally likely that the surgeon or surgical environment influenced the patient'due south outcome. We must as well be cautious in generalizing the findings of these two studies from data nerveless in the late 1990's to current hospital conditions. Although a contempo review of nearly a hundred nurse staffing studies by the Agency for Healthcare Quality and Research found an clan between staffing levels and patient mortality and hospital effect, the authors ended that these relationships are non causal (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). The bachelor testify does non back up the establishment of specific nurse-to-patient staffing ratios at this time; and the extant literature contradicts the legislative efforts endorsed by those seeking mandatory, nurse-to-patient staffing ratios. The American Hospital Association (AHA), forth with its individual member state associations, have universally opposed laws mandating any specific nurse-to-patient staffing ratio. The AHA has argued that nurse-to-patient staffing ratios reduce scheduling and staffing flexibility. The American Organization of Nurse Executives also opposes mandatory ratios and has chosen for a more than balanced approach through increased monitoring of nurse staffing, improved recruitment and retention approaches, and development of undergraduate nursing education (American Arrangement of Nurse Executives, 2003).
Some other trouble related to mandatory staffing ratios is the cost associated with hiring new nurses. For case, consider a medium-size hospital that has on boilerplate 100 adult medical-surgical patients. An increase of but i hour of additional care by a registered nurse per day at $40 per hour would increase costs by $4,000 per solar day and $ane.4 one thousand thousand dollars annually. The infirmary will not receive whatever additional revenue for providing this additional patient care. This illustrates the underlying issue of how nursing care is currently billed and reimbursed in the acute care setting. Every bit of the writing of this article, in that location is no straight accounting of nursing intensity or costs for individual patients, only a single mean toll of nursing intendance per patient day without any acknowledgment in the billing or payment system that different patients crave different levels of nursing intendance. This lack of additional payment to a hospital creates a strong disincentive for hospitals to increase staffing and is one of the main reasons the hospital associations are fighting these proposed laws equally they announced in diverse statehouses across the Us.
Mandatory, nurse-to-patient staffing ratios purport to address the perceived imbalance between patient needs and nursing resources even so they do non address the very different levels of treatment complexity and nursing intensity among patients in a given unit. A report recently reported that the hateful unit of time needed to intendance for patients having a specific diagnoses varied widely inside each DRG category (Welton, Zone-Smith, & Fischer, 2006). Nursing intendance intensity and costs tin can as well vary widely among patients on the aforementioned unit, across multiple similar units in the same hospital, and across similar units at many hospitals, based, for case, on differences in patient age, disability, expected self intendance, and cognitive level.
In a study of Massachusetts hospitals, significant differences were found for nurse-to-patient staffing ratios, intensity, and skill mix amid like types of units (Welton, Unruh, & Halloran, 2006). The distribution of hateful care hours per patient twenty-four hour period (staffing intensity) for adult medical/surgical units in community hospitals was significantly different than similar units at academic medical centers. The analysis was based on publicly reported information from the Massachusetts Hospital Association Patients First staffing database (Massachusetts Hospital Association, 2006). For example, nurse-to-patient staffing ratios on the adult units were 1:5.25 for community hospitals and 1:four.08 for academic medical centers. The imposition of mandatory, nurse-to-patient staffing ratios of one:four for all hospitals, as advocated by the Massachusetts Nurses Association (not to be confused with the Massachusetts Association of Registered Nurses which is the elective member of the ANA), does not conform to the actual differences across hospitals past patient, nurse, and unit characteristics that currently exist in Massachusetts (Curtin, Gall, & Vigue, 2006). A uniform, state-wide ratio would burden smaller community hospitals as they take lower severity patients, yet would be required to staff at the same level as the larger teaching hospitals.
Nursing Intensity Billing as an Alternative to Mandatory Nurse-to-Patient Staffing Ratios
As more than and more than states introduce legislation to address the symptom, but not the crusade of understaffing, it may be fourth dimension to consider an culling to mandatory ratios - i that does address this crusade past considering the intensity of nursing care need for a given patient. Since infirmary fiscal decisions are directly linked to payment for patient care, ...changing nursing from a toll center to a revenue center could alter the dynamic between nurses and hospitals. irresolute nursing from a cost center to a acquirement center could change the dynamic betwixt nurses and hospitals. A cost eye is the accumulated direct expenses, such as nursing salaries, and indirect expenses, for example electricity and laundry, for a particular unit of measurement. In the Medicare Toll Report, all routine intendance unit and intensive care unit costs are summarized equally two separate categories. Acquirement codes are used for billing for specific items of care such as lab tests, needed supplies, and medications. These charges are grouped to specific revenue centers that correspond with their respective cost centers, generally divided between adaptation and ancillary services. Since in that location is no direct allocation of nursing intendance to a specific billing code, nursing is not considered to generate any acquirement for the infirmary and is expressed only as a cost.
Only stated, if Medicare and other payers for health care directly reimbursed hospitals for the actual nursing care given an private patient, rather than bundling this intendance within a fixed room and board cost center based on hospital average nursing time and costs, hospitals would benefit by a more than equitable payment system as the charges for nursing care would be equivalent to the associated costs for individual patients. The following section volition describe the current hospital reimbursement system for nursing care, suggest a new reimbursement model, discuss the benefits of this new model, and explain how this model tin accept a positive influence on health care policy.
Current Reimbursement for Nursing Intendance
In the current organisation, hospitals allocate all patient intendance expenses to specific categories or toll centers that map to the Medical Cost Study (Centers for Medicare & Medicaid Services, 2005; Centers for Medicare & Medicaid Services, 2006). For example, medications would map to the pharmacy cost center, and an electrolyte panel would map to the lab cost center. Currently direct nursing costs are allocated to one of only 2 accommodation cost centers: routine (floor) intendance and intensive care. All nursing costs are treated equally a lump sum and and so averaged and standardized per patient 24-hour interval. Since straight nursing care hours and costs are highly correlated, this bookkeeping approach implies that all patients inside either the routine or intensive toll centers receive the aforementioned level of nursing care (Welton, 2007). All hospitals receive the same payment for a given diagnosis, based on the DRG relative weight. Standardized nursing costs per patient twenty-four hours are used to set these weights, rather than the individualized amount of care given a particular patient. This creates a distortion or bias in the DRG-based system in that nursing care is held at a abiding cost per patient day and then does non affect the relative weight used to calculate the actual hospital reimbursement despite the fact that nursing intendance makes upward 41% of all hospital costs (Dalton, 2007).
A New Model for Reimbursement of Nursing Care
A plan to create a national model for inpatient nursing intensity billing and reimbursement has been proposed to correct the inherent problem of treating nursing intendance every bit a stock-still cost (Welton, 2006). The underlying principal of a nursing intensity billing model is to unbundle nursing intendance costs and billing from the traditional and archaic "room and board" charge and to instead establish costs based on the intensity of the care received past each patient. The model uses one of the existing revenue codes currently used to charge for all inpatient services (023x Nursing Incremental Accuse) as a ways to business relationship for nursing care delivered to individual patients (Welton, Fischer, DeGrace, & Zone-Smith, 2006a). These acquirement codes are administered by the AHA with input from diverse payers and other stakeholders through the National Uniform Billing Committee (AHA, 2006). These revenue codes map to related cost centers as mentioned in a higher place to determine a cost-to-charge ratio in order to make up one's mind payment because Medicare only pays for actual costs, not what hospitals charge for their services. A list of the standardized revenue codes tin can be found on the New York State Department of Health website (New York State Department of Health, 2007).
Benefits of the Nursing Intensity Billing Model
Billing separately for straight nursing care using the Nursing Incremental Charge revenue lawmaking for actual hours and costs would address several issues identified in a higher place. Showtime, a direct bookkeeping of actual nursing intendance fourth dimension and costs for each patient would change how nursing care is allocated from a department-based scheme to one based on resource expended for individual patients (Finkler & Ward, 2003). This could eventually change the relative weights for individual DRGs to more than closely match the actual costs of nursing intendance with payment inside a given DRG.
A 2nd issue that has generated growing concern is the proliferation of specialty hospitals that accept only a narrow range of relatively low severity only high acquirement-producing patients. These hospitals tend to specialize in cardiac and orthopedic procedures; they siphon potential revenue from community and educational activity hospitals that rely on these patients to get-go losses from their more severely ill patients, i.e., those patients who consume a greater than average amount of hospital resource, just for whom the infirmary does not receive additional payment (Medicare Payment Advisory Commission [MedPAC], 2005). To a sure degree, these specialty hospitals are taking advantage of the college, relative reimbursement for nursing care provided to patients needing less than the standardized level of nursing care. This occurs because the DRG treats all nursing care as a stock-still daily rate in relative weights used to calculate payment (Greenwald, Cromwell, Adamache, Bernard, Drozd, Root et al., 2006; Guterman, 2006; Stensland & Wintertime, 2006). Since these patients may require less nursing care than patients in other (non-specialty) hospitals, the hospital receives a relatively higher payment, given that the DRG relative weight is an aggregate of cost in all hospitals (Dalton, 2007).
Considering fourth dimension equals money (Thompson & Diers, 1991) there are a number of other advantages to identifying the needed, directly nursing care hours, a measure of direct nursing costs needed for a given patient, rather than using wide, department hateful hours and costs per patient day. First, transitioning to a nursing intensity billing mechanism allocating actual nursing resources (time and costs) would ultimately align nursing costs with associated hospital reimbursement (Welton, Fischer, DeGrace, & Zone-Smith, 2006b).
Additionally, data used to charge for hourly nursing care time would be included in the national data repository used for setting rates, wellness intendance policies, and conducting health services research. ...information used to accuse for hourly nursing intendance time would be included in the national data repository used for setting rates, health care policies, and conducting health services inquiry. A national repository of nursing intensity data linked to discharge, medical diagnosis (e.one thousand. DRG), and other authoritative data would let comparing of nursing care across multiple institutions. These data would allow benchmarking and trend analysis across hospitals to provide a more robust measure of the relationship betwixt nurses and patient care quality/outcomes of care compared to existing measures that apply hospital-level, average nurse-staffing levels (Welton, 2007). For example, aggregate floor intendance and intensive intendance nursing hours from the 023X revenue code charges and units (hours of daily nursing care billed for an private patient) for each DRG could be used as a normative reference for both staffing and cost estimation. Hospitals would then be able to compare their mean nursing intensity past DRG with other hospitals. Those hospitals falling well below a mean level may be providing less nursing care than other hospitals, thus raising potential problems of quality and condom. Hospitals that are providing substantially more than the mean corporeality of nursing care time past DRG may be inefficient or providing more nursing staff than required for that case mix of patients.
This repository of nursing intensity data could too represent the initial implementation of the nursing minimum data set envisioned by Harriet Werley and many others over ii decades agone (Werley, Devine, & Zorn, 1988). Nursing intensity was one of the four nursing-specific items to be included in the Nursing Minimum Data Set along with nursing diagnosis, nursing interventions, and nursing outcomes. Although there has been significant progress over these thirty years in explicating nursing terminologies and codes (Lunney, Delaney, Duffy, Moorhead, & Welton, 2005), their actual apply in the billing and discharge data sets has not been accomplished to date.
The current effort to collect inpatient nursing data within the National Database of Nursing Quality Indicators (NDNQI) may provide a template for collecting amass information that can be used to compare nursing care across multiple institutions (Trossman, 2006). The NDNQI measures quarterly nurse staffing patterns and unit-based, quality indicators such equally pare breakdown and falls. This national NDNQI attempt, with over m participating hospitals, does demonstrate a way to compare nursing intendance across multiple settings. However, the NDNQI data are collected at the unit level, not the individual patient level. Hence, the usefulness of this information for direct billing for nursing care may be limited.
A third benefit of a nursing intensity billing model is that it could provide the footing for a pay-for-operation, more recently termed a value-based-purchasing, reimbursement mechanism (Baker, 2003). In the example above, a national or regional comparing of nursing floor care and intensive care mean hours and costs by DRG tin be used in combination with quality, outcome, and patient-rubber data to reward hospitals that provide superior nursing care at the least cost. Unfortunately, any machinery to pay for inpatient nursing operation may advantage hospitals that are already providing excellent intendance. It may and so potentially exacerbate problems of quality for hospitals that are not providing acceptable staffing for reasons that may be hard to overcome such as providing intendance in rural settings. The current accent on medical and hospital pay-for-operation does not adequately address nursing care primarily due to the lack of information virtually the interaction between a given nurse and a specific patient (Bakery, 2003; Frolich, Talavera, Broadhead, & Dudley, 2007; Milgate & Cheng, 2006).
Moving towards a nursing intensity billing model based on the existing nursing incremental charge (023X) would provide new data about the nursing care of hospitalized patients contained of the medical diagnosis. Nevertheless, much more study is needed to clearly define the part of nurses in achieving high quality hospital operation, and to devise methods to arrange payment based on that performance. The first step towards that goal is to identify the optimum level of nursing care for each patient – not more than, not less. It is anticipated that the Centers for Medicare and Medicaid Services, as well equally other payers for inpatient care, volition more than likely conform hospital payment if data are bachelor to link nursing intendance intensity with patient needs and resulting outcomes/quality of care.
Impact of the Nursing Intensity Model on Health Care Policy
Straight reimbursing hospitals for nursing care is not a silver bullet and will non immediately improve conditions at those hospitals with the highest nursing workload. Rather, it is a long-range strategy to enhance the visibility of nursing at the highest levels of health care policy development, thus increasing the focus on health intendance relative to health cure. Directly reimbursing hospitals for nursing care...is a long-range strategy to raise the visibility of nursing at the highest levels of health intendance policy development, thus increasing the focus on health care relative to health cure. Nursing-intensity billing would provide an culling, market-based approach compared to mandatory nurse-to-patient staffing ratios, an approach that both hospital associations and nursing labor organizations could potentially embrace.
An intensity-adjusted payment for inpatient nursing care received past a hospital could become a acquirement stream and decrease the incentive to cut nursing positions. Currently hospital nursing care is cantankerous subsidized (Dalton, 2007). For example, hospitals may receive reimbursements that are higher than actual costs for certain interventions, typically in surgical or procedural types of DRGs. This higher reimbursement is related to the electric current dominance of ancillary (procedural) charges compared to accommodation (room and board) charges in the payment system (Cromwell, Drozd, Gage, Maier, Richter, & Goldman, 2005; Cromwell, Maier, Gage, Drozd, Osber, Richter et al., 2004; Drozd, Cromwell, Gage, Maier, Greenwald, & Goldman, 2006). The backlog of revenue to costs in reimbursing interventions is used to first the lower payment to cover boosted nursing costs associated with certain types of patients, typically medical patients.
Inclusion of an independent nursing adjustment to hospital payment would provide additional information to policy makers to determine how health care resource are expended. The reallocation of health intendance dollars, or at a minimum the consideration of nursing intendance relative to each diagnosis (DRG), would provide a residuum to the most full emphasis on the medical aspects of inpatient care. Linking inpatient nursing care to the billing system would provide a way to balance the ancillary charges related to procedures, operations, and other medically related curative methods, with the associated nursing care embedded inside the accommodation charges.
In summary, the introduction of a nursing intensity billing model has the potential to provide crucial data that has been missing for so many years. Information about the distribution of nursing intensity and needed skill mix provides a ways to evaluate the human being capital needed to intendance for patients. It provides a manner to balance intendance (routine and intensive care costs related to nursing activities) with cure (coincident charges related to procedures, drugs, radiology, and other technical interventions). We demand to do both well. Unfortunately the existing payment system does a poor chore of estimating nursing care needs.
Sources of Funding for Nursing Intensity Billing
An important question to enquire is where the money to pay for a nursing intensity billing model might come from if it were implemented nationally. The answer is that initially at that place would be a shift in reimbursement, from over-compensated procedures to medical patients, such as stroke, pneumonia, and urosepsis patients, who have relatively higher nursing care needs (Welton, Halloran, & Zone-Smith, 2006). Equally noted previously, this overcompensation is related to the manner in which current hospital reimbursement can be increased past ancillary charges, whereas nursing care is locked into a fixed room and board per diem charge (Dalton, 2007). Billing direct for nursing intendance would reallocate reimbursement to more nursing intensive patients.
Another source of income could come from the render-on-investment of improved intendance resulting from an acceptable number of nurses providing the care. Both higher percentages of registered nurses to all nursing staff (RN%) and overall higher number of nursing care hours may lead to lower infection rates, falls, peel breakdown, failure to rescue, and unnecessary inpatient decease, leading to overall lower costs of intendance (Needleman, Buerhaus, Stewart, Zelevinsky, & Mattke, 2006). The change in payment, from utilize of the mean infirmary nursing costs to increased payment for patients requiring more than intense nursing intendance, could allow hospitals to improve staffing for those patients who have traditionally required more nursing care than was reimbursed. However, it is hard to predict how hospitals would actually respond to these increased payments every bit there is no accountability for hospitals to increase nurse staffing for whatever particular patient just because the payment they receive is increased.
Weaknesses and Limitations of Nursing Intensity Billing
In that location are a number of key issues that may diminish or forbid implementation of a nursing intensity billing model. First, the demand to collect real-time data regarding hours of nursing care is labor intensive and decumbent to error, bias, and missing information. For instance, nurses may enlarge the time they spend actually providing nursing care; or if too busy they may not record bodily nursing fourth dimension. Second, there is a potential for fraudulent billing if the actual number of nursing care hours was lower than what was actually charged. A 3rd result could exist patient response upon receiving their hospital bill. Patients may written report that they did not receive all the nursing intendance indicated in the bill considering some, if not much, of nursing time is spent away from the patient's bedside. A forth upshot might be the need to compare nursing-care intensity across different patients and hospitals. It has already been noted that the medical diagnosis correlates merely weakly with nursing care time; hence billing for nursing care within the DRG is problematic (Welton & Halloran, 2005). It is also possible that regional differences in nursing intendance could influence the intendance given and hence, payment to hospitals, if a nursing intensity billing model was implemented. Smaller hospitals may be at college hazard as they tend to take patients requiring less intense nursing care. Hence smaller hospitals may be more afflicted by changes in instance mix and census than larger hospitals (Dalton, 2003; Dalton, Holmes, & Slifkin, 2003).
Determination
In summary, I recommend that all proponents of mandatory, nurse-to-patient staffing ratio laws consider the alternative of improving staffing levels past reimbursing nursing care based on the intensity of the care given. In addition, a nursing intensity billing model could reestablish the link between nurses and patients. It could help nurses demonstrate the value of what they do for patients. Currently we cannot bear witness the economical value of nurses because we lack the data to do so. Currently we cannot testify the economic value of nurses considering we lack the information to do and then. Linking nursing intensity, straight costs of care, and payment for that care inside the billing and reimbursement system could greatly change the relationship betwixt nurses and hospitals. Information technology could provide data needed to increment staffing levels and subsequent quality of care, and result in better hospital performance in the long run.
Mandatory nurse-to-patient staffing ratios may exacerbate, rather than correct, the imbalance between patient needs and available nursing resources in U.Due south. hospitals considering patients have different intendance needs. The prove has clearly demonstrated that many factors related to nurses, patients, and hospitals create a high degree of variability in nursing intensity. Creating a single ready of national or state nurse-to-patient staffing ratios could create a situation in which some patients receive more nursing care than needed, and others less care. This could pb to lower quality of intendance and higher costs. Mandatory nurse-staffing ratios may exacerbate rather than correct the imbalance between patient needs and bachelor nursing resources in U.Due south. hospitals because patients have dissimilar care needs. In dissimilarity, optimizing nursing intensity based on actual patient needs could address the perceived nursing shortage by creating a improve fit between patient demands and the nursing resource used in the clinical setting. The nursing intensity billing model is able to provide much greater flexibility in matching needed nursing resources with hospital reimbursement... The nursing intensity billing model is able to provide much greater flexibility in matching needed nursing resources with hospital reimbursement than the mandatory, nurse-to-patient staffing ratios. The information used to unbundle nursing intendance from room and board charges could also provide crucial data to compare nursing intensity by diagnosis across multiple patients and hospitals.
Ultimately, the nursing intensity billing model provides an incentive to hospitals to improve nurses staffing past investing in nursing intendance, irresolute nursing care to a revenue source, and comparing or benchmarking hospitals to regional and national norms based on the administrative information. In the hereafter, this billing model could lead to establishing normative standards for inpatient nursing performance and creating methods to arrange payment based on the merits of the nursing care provided.
Author
John M. Welton, PhD, RN
E-mail: weltonj@musc.edu
Dr. John Welton is an Associate Professor and Faculty Chair at the Medical University of S Carolina Higher of Nursing. He is a graduate of the University of North Carolina PhD program in nursing; he has researched inpatient nursing intensity and staffing patterns and published widely on the field of study. He is as well a member of the American Organization of Nurse Executives nursing intensity task force to examine the potential of a national nursing intensity billing model. He is currently funded past AONE to carry a pilot study evaluating the nursing intensity billing model.
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Article published September 30, 2007
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