Mandatory Hospital Nurse to Patient Staffing Ratios: Time to Take a Different Approach

Proponents of mandatory, inpatient nurse-to-patient staffing ratios have lobbied state legislatures and the United States Congress to enact laws to improve overall working conditions 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 being harmed by inadequate staffing related to increasing severity of illness 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 will be needed for the higher, mandated ratios will not be offset by additional payments to hospitals, resulting in mandates that will be unfunded. An alternative approach would be to provide a market-based incentive to hospitals to optimize nurse staffing levels by unbundling nursing care from current room and board charges, billing for nursing care time (intensity) for individual patients, and adjusting hospital payments for optimum nursing care. The revenue code data, used to charge for inpatient nursing care, could be used to benchmark and evaluate inpatient nursing care performance 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 within the next few years have already been initiated. This article will argue for the benefits of implementing a nursing intensity adjustment for nursing care by briefly 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 against mandatory, nurse-to-patient staffing ratios; offering 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.