Hospital Billing and Reimbursement

The moral agency of institutions: effectively using expert nurses to support patient autonomy

Patient autonomy-with an emphasis on informed consent and the right to refuse treatment-is a cornerstone of modern bioethics. Within discussions about patient autonomy, feminist bioethicists have argued for a relational approach to autonomy. Under a relational framework, we must look beyond the individual moment of choice to include the role relationships and specific contexts can play in supporting or undermining autonomy. Given the day-to-day interactions they have with patients, nurses play a significant role in helping patients understand the nature of their illnesses and make truly informed decisions. However, the skills of expert nurses also support patient autonomy in more subtle ways. Specifically, nurses develop skills of attunement that help them to find subtle ways to support patient autonomy. However, in order to effectively do this, nurses need institutions that support their professional autonomy. In this paper, I look at the ways nurses have been inhibited in their professional autonomy both as a profession and as individual practitioners. I argue that turning our attention to institutions and the role they play in supporting or undermining nurses' autonomy can help promote nurses' professional autonomy and thereby enhance patient autonomy.

Costing nursing care: using the clinical care classification system to value nursing intervention in an acute-care setting

The purpose of this study was to combine an established methodology for coding nursing interventions and action types using the Clinical Care Classification System with a reliable formula (relative value units) to cost nursing services. Using a flat per-diem rate to cost nursing care greatly understates the actual costs and fails to address the high levels of variability within and across units. We observed nurses performing commonly executed nursing interventions and recorded these into an electronic database with corresponding Clinical Care Classification System codes. The duration of these observations was used to calculate intervention costs using relative value unit calculation formulas. The costs of the five most commonly executed interventions were nursing care coordination/manage-refer ($2.43), nursing status report/assess-monitor ($4.22), medication treatment/perform-direct ($6.33), physical examination/assess-monitor ($3.20), and universal precautions/perform-direct ($1.96). Future studies across a variety of nursing specialties and units are needed to validate the relative value unit for Clinical Care Classification System action types developed for use with the Clinical Care Classification System nursing interventions as a method to cost nursing care.

Testing an inpatient nursing intensity billing model

There has been growing concern about the costs and intensity of inpatient nursing care, which consumes more than 40% of hospital direct costs and $165 billion each year. Allocating nursing labor as an average cost per patient and charged as room and board creates cost compression, distorts hospital payment, and hides the economic value of nurses. This article examines a method for adjusting daily room charges using nursing intensity weights assigned by the diagnosis related group. In a test using claims data from 286 hospitals in four states representing 1,856,256 patient discharges in 2002, the nursing intensity adjustment improved explained total cost variance by 8.5% for adult all payer patients (R2 = .4448 vs. .4825) and 9.4% for Medicare only patients (R2 = .4387 vs. .4798) compared to unadjusted days. This article discusses unbundling inpatient nursing care intensity and charges from room and board and recommends implementing this billing process at all U.S. hospitals.