Preparing a lecture led me to research articles on nursing reimbursement. In my January 2023 editorial, "Classifying nursing as a cost comes at a high price," I noted that nursing care is rolled into the room and board charges listed on hospital bills. Nursing care is not listed as a separate line item the way fees for other health professionals are included. I wanted to find out why-and my literature search steered me to follow the money.
This reimbursement saga began before the 1930s when nurses predominantly cared for patients in their homes. Nurses were paid directly by patients or family members. These nurses would also provide private duty care to patients in hospitals and receive remuneration for their services. Nurses were largely self-employed and could compete with hospitals and doctors economically.1,2 In the 1930s, the Social Security Act contained a reimbursement model for nursing services that bundled nursing care under patient room and board charges. The model design was allegedly influenced by hospital administrators to intentionally render nursing services invisible on the hospital bill so that there was no economic connection to nursing.2,3 Purposeful or not, making the contribution of nursing invisible effectively served to devalue the profession.3
As growing numbers of patients required care in hospitals, more nurses were hired as staff.1,2 Moving from a self-employment to an employed status shifted the position of nurses from a revenue-generator to an expense for the hospital. Since the value of nursing was disconnected from hospital revenue, administrators exerted tight budgetary control over the delivery of nursing services in efforts to reduce costs.
The nursing profession has undergone much change since the 1930s; this near-century-old reimbursement model also must change through legislation. This is not a new aim. Multiple publications since the 1980s advocate uncoupling nursing from room and board charges. It may even be a key to solving today's nurse staffing crisis.2 If nursing care becomes a reimbursable service, financial incentives are created to right size nurse staffing. Nurses move from the expense to the revenue category to better sustain the profession's future.2 The American Nurses Association is a leader in this effort.4 This Thanksgiving, I am grateful to those endeavoring to elevate nursing reimbursement beyond the dark ages.
Until next time,
LINDA LASKOWSKI-JONES, MS, APRN, ACNS-BC, CEN, NEA-BC, FAWM, FAAN
EDITOR-IN-CHIEF, NURSING2023