On Lobby Waterfalls and Safe Staffing

  

Limousine service, upgraded television sets, nurse-to-patient “scripts,” gourmet food service, nurse uniform requirements. Hospitals all over the U.S. are offering more “customer-centric” patient care in order to increase patient satisfaction scores, which are becoming ever more important to raise and maintain Medicare reimbursement amounts.

These efforts, however, often have unintended consequences.

In the first place, customer-centric interventions rarely (if ever) improve the quality of care patients receive. Rather, they merely improve patients’ perceptions of care.

Perhaps the biggest issue with this approach is that nurses have little control over the factors that research shows improve patient satisfaction scores the most. Quality of food service, wait times, physician attentiveness, even staff uniform colors are all factors in patient satisfaction scores—none of which nurses have control over.

Crucially, nurses also have little control over nurse staffing, which research demonstrates is a significant factor in patient satisfaction scores. Short staffing is inherently unsafe and puts patients at risk.

Contrary to gourmet food service, however, improving nurse staffing actually improves the quality of care patients receive, not just their perception of it. The literature shows that improving nurse staffing while controlling for variables (including physicians, LPNs, and nursing assistants) significantly reduces the risk of mortality, lowers the incidence of medication errors and other adverse events, lowers patient readmission rates, reduces nursing-sensitive negative outcomes, and even saves hospitals and insurance companies money—and that’s just the tip of the iceberg.

In an effort to mitigate the unintended consequences of patient satisfaction scores and improve nurse staffing, the American Nurses Association has long advocated for Medicare to include nurse staffing measures next to patient satisfaction scores on its Hospital Compare website.

By doing so, public reporting of nurse staffing on a 1-5 scale will push hospitals to staff more safely and shift patient care interventions from those that improve perceptions of care to those that actually improve care itself. Think about it: nurse staffing is perhaps the single greatest indicator of patient quality of care. Would you rather go to a facility with a five star rating on nurse staffing, or one with a three star rating on nurse staffing, two lobby waterfalls, great patient scripting, and state of the art flat screen tvs?

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Give me the better nurse staffing every time.

Unfortunately, Medicare recently declined to include nurse staffing measures on Hospital Compare for Fiscal Year 2018. But the fight is not over. While ANA is proud that we were able to help generate 1,363 comments in support of these staffing measures, and is thankful for the 26 advocacy groups who co-signed our comment letter to the Center for Medicare Services, we are already gearing up for an even bigger grassroots movement next year.

But we’re going to need your help. Stay tuned for more: #nursesunite.

Trump Administration Moves Create Major Uncertainty In Healthcare System

  

The Trump administration has toyed for months with the idea of withholding cost-sharing reduction (CSR) payments to insurance companies participating in the individual insurance marketplace implemented by the Affordable Care Act (ACA). This has injected a great level of risk into the healthcare system which has in turn created a lot of uncertainty and confusion. These CSR payments are intended to help low-income individuals with income between 100% and 250% of the federal poverty level pay for co-pays, co-insurance, and deductibles. The ACA limits to a percentage of their income the amount of cost-sharing these individuals pay. For instance, an individual with an annual income of $17,000 might only have a $125 deductible compared with a $2,500 deductible for someone with a $25,000 annual income under the same insurance plan. (See a detailed description of CSR payments here). The federal government makes CSR payments to insurance companies to balance out the difference between what the individual pays and what the insurance company charges (fortunately, the Trump administration today stated that it will make CSR payments for August).

The Congressional Budget Office (CBO) on August 15th released an analysis on the impact that withholding the CSR payments would have on insurance premiums and insurance coverage. According to the CBO report, insurance premiums for individual insurance coverage would increase by 20 percent in 2018 and by 25 percent by 2020, while 5 percent of people would live in areas that would have no insurers in the non-group market in 2018.

Furthermore, withholding CSR payments would increase the federal deficit by $194 billion from 2017 through 2026, largely as a result of higher federal premium tax credit payments. Higher federal deficits would also put pressure on existing federal healthcare and social services programs, including Medicaid, and would further threaten the ability of the federal and state governments to provide health care services to the nation’s vulnerable populations.

In addition to the chaos and uncertainty the Trump administration is causing with respect to CSR payments, it is also making moves to undo some of the progress made under the ACA toward achieving quality outcomes and a higher degree of care coordination. A recent rule proposal published on the website of the Office of Management and Budget would eliminate the mandatory implementation of the bundled payment models for cardiac care coordination and cardiac rehabilitation, as well as implement changes to the comprehensive care joint replacement model. These advanced payment models promote care coordination and place an emphasis on patient outcomes and quality of care; elimination of these models would be a detriment to patients and nurses alike.

Stable payment systems and innovative payment models which emphasize care coordination and patient outcomes will better enable nurses to provide quality care and ensure that patients are able to receive the best quality of care in a timely fashion and with better outcomes. As such, the American Nurses Association strongly supports both the federal CSR payments and the implementation of the aforementioned advanced payment models.

State Nurses Associations ask Legislators to Consider the Facts on Nursing Practice

  

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As nurses and consumer advocates in Texas fought for full Advanced Practice Registered Nurse (APRN) practice authority this past legislative session, those opposing the measure trotted out an unlikely source: a patient who had suffered harm at the hands of an APRN. Likewise, nurses and consumers in Oklahoma were stymied in their push for full practice authority when a legislator expressed concern with a growing rate of malpractice claims against APRNs. But when you step back from arguments that are based on emotion and anecdotes, all that’s left are facts—and facts are stubborn things.

In this instance, the facts show that the arguments against full APRN scope of practice in Oklahoma and Texas don’t hold water. Take the patient who was harmed, for example.  While it’s undoubtedly true that patients are sometimes harmed in the delivery of healthcare, what truly matters is whether APRNs are able to practice safely and effectively in comparison to what one might expect from other healthcare providers. And, as this space has covered, APRNs fare well in that analysis. Indeed, as the National Academy of Healthcare noted, “the contention that APRNs are less able than physicians to deliver care that is safe, effective, and efficient is not supported by the decades of research that has examined this question.”

This is further borne out by malpractice claims and payout data, contrary to the concerns of the legislator from Oklahoma. Some of the most recent data available from the National Practitioner Databank, a national repository of malpractice claims and payouts, shows that nurse practitioners did  experience an 18% increase in malpractice claims from 2007-2011. And yet, during that same time, the number of nurse practitioners increased by a whopping 28%. The fact is that although malpractice claims increased by 18%, they should have increased by 28%, in line with the increase in nurse practitioners. In other words, nurse practitioners actually improved their safety as determined by the rate of malpractice claims during the study timeframe.

What’s more, a 2013 American Association of Nurse Practitioners’ study of the National Practitioner Databank found that the malpractice payment rate for nurse practitioners was half that of Physician Assistants and ten times less than that of MDs and DOs. Put another way, while it’s true that one in a thousand APRNs made a malpractice payout during the study period, that was a much lower rate than the one in five hundred PAs, or the one in one hundred MDs/DOs.

Facts are stubborn things. And here are some for states without full APRN practice authority to consider: APRNs practice safely, effectively, and cost-efficiently, and are much less likely to harm patients or pay out malpractice claims than other healthcare providers.