The medical alert blared over the hospital’s public announcement system. Someone was down in the medical office building. A medical team, including myself and a doctor, rushed with a portable cot to find a man in his early 30s unconscious on the waiting room floor.
The man hadn’t been feeling well and was waiting to see his doctor when he passed out. We whisked him to the ER, and I ran routine tests as he regained consciousness, including a lactic acid to test for sepsis. He was anxious and worried about his wife and young daughter.
The doctor opted not to submit that test. My nurses’ intuition told me it was a mistake, and I shared my concern, but there’s a pecking order in hospitals, and nurses are near the bottom. Despite my protests, the patient was discharged hours later, and I closed out my shift feeling uneasy. When I returned to work the next morning, I learned he had been rushed back to the ER overnight, deathly ill in septic shock. He ended up in a permanent vegetative state; he’d never see his daughter grow up, all because the doctor wouldn’t budge on submitting a test.
Later, I was at the center of an investigation by the hospital’s risk and legal department. The doctor did not have to participate. That was the moment my feeling of powerlessness crystallized. Feeling disrespected by the health care system, I began to question my value as a nurse. That feeling hasn’t stopped.
A relic of an antiquated economic system
Women account for 87 percent of the nursing workforce. As the U.S. health care system evolved in the early 20th century, physicians – almost all of whom were men – began to assert their power through institutions, regulatory bodies, policies, and associations. Like so many historical imbalances, economics drew delineations that only deepened the inequity.
This gendered hierarchy reaches back to the earliest days of modern medicine, but was codified when the Medicare and Medicaid Act was signed into law in 1965. Almost everything in the hospital, from services to goods to a physician’s time, is billable. The services nurses provide are not. Our services are folded into the line item for room and board. It’s the same fixed cost for every patient.
Though gender roles in medicine have blurred, the early patriarchal design of the payment system persists, denying economic power to the caregivers who spend the most time with patients. This is the nurse’s conundrum: Everyone knows how critical we are to the health care system, but we’re almost entirely bereft of economic agency within it. There’s a direct line from that diminished status to my recommendation for a lactic acid test being refused. Would nurses’ stature in a medical team improve if our economic value was properly calculated?
Calculating the value of a nurse
“The dearth of evidence on new, existing, and proposed compensation models is striking,” researchers wrote in a 2022 study on nursing payment models. “To our knowledge, there is no evidence-based gold standard in clinician compensation.”
In 1988, Harvard economist Dr. William Hsaio devised an algorithm to determine the value of physicians’ work. The measure, called a relative value unit (RVU), was adopted by Medicare in 1992. RVUs include the time physicians spend, the costs associated with their services, and the cost of malpractice insurance. They’re directly tied to every service physicians provide.
Large trade associations have proven able to manipulate this system. It’s inflationary, but it’s the system we have. What if it accounted for nurse services?
Chief among the list of pros is the impact on the labor market. Nurse compensation would better reflect the economic value of our work. That could draw more talent into the field, possibly enough to quell the worst nursing shortage our country has seen to date. It could disrupt the structure of power in hospitals.
The cons could be weighty. Billing for nurse services would affect health plans, hospital administrators, billing departments, clinicians – and patients. A separate payment system for nurses could follow the same escalations that have made health care unaffordable to many. If doing what’s right for nurses means doing wrong by everyone else, is it worth it?
A few hospitals have experimented with a system that incorporates nurse services, with some success, but it’s been widely criticized – in part because nursing is not a task-based profession. Our job is equal parts intellect and compassion, and requires the ability to flex to patients’ mental, physical, and emotional needs.
How do you bill for that? I’m not sure. No known fix would have net positive impacts.
This much is clear: The status quo is not working for nurses. If health care policymakers don’t find a solution soon, our absence may finally reveal our true value.
Susan Pasley is a nurse executive.
