Health Law (HL)

Quality and Value-Based Patient Care is No Fixed Number

By Lorianne Sainsbury-Wong posted Mon November 05,2018 06:37 AM


Federal funding initiatives recognize nursing as a critical component in the delivery of quality patient care and value-based reimbursements to most hospitals.  Hospital stakeholders, such as nurses, collectively contribute to improved quality and performance while reducing costs through incentivized reimbursement methods under programs established by the Patient Protection and Affordable Care Act (ACA). The ACA, however, does not mandate nurse to patient ratios. Instead, it improves the delivery of healthcare by authorizing the Centers for Medicare and Medicaid Services (CMS) to implement value-based programs that correlate hospital reimbursements to compliance with benchmark performance standards.  CMS addresses the adequacy of nursing services as a condition of Medicare participation and reimbursement. For example, Medicare implementing regulations state, in part, that hospital nursing directors effectuate the quality and operation of healthcare services by ensuring that hospitals "have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses and other personnel to provide nursing care to all patients as needed." 42 C.F.R. § 482.23(b).

CMS guides providers to improve their quality of healthcare services and encourages hospitals to develop compliant and innovative strategies that further reduce administrative burdens and control costs.  By extending its financial leverage, Medicare policies result in coordinated stakeholder efforts, which include hospitals and workforce, to safeguard the quality of patient care and reduce costs with no fixed number sets of nurse to patient coordinated care teams. Some Medicare programs link federal reimbursements to those hospitals with improved quality of care to patients and reduced costs — none of which rely on mandated hospital nurse staffing ratios.  The Hospital-Acquired Conditions (HAC) Reduction Program, the Hospital Readmissions Reduction Program (HRRP), and the Value-Based Purchasing (VBP) Program are examples of performance standards that govern financial reimbursements under CMS’s incentive-based payment system.  

It’s not mandated nurse to patient ratios that matter in these CMS programs but rather the extent to which Medicare hospitals maximize their performance rankings by investing in evidence-based services and outcomes, such as nursing care.  Hospital nurses are significant stakeholders in these federal programs because they provide  affordable, high-quality services to patients. Mandating fixed nurse to patient ratios is not necessary as these Medicare programs already incentivize hospitals to adjust staffing levels according to patient safety and quality of performance outcomes.
Lorianne M. Sainsbury-Wong, Esq., CPCO  
Civil Litigation Section Council Member (2016 – present) 
Health Law Section Member, Chair (2014-2016) and Co-Chair (2013)