Home > RNJ > 2011 > November/December > Guest Editorial: Debt Crisis: Opportunity for Nursing Action

Guest Editorial: Debt Crisis: Opportunity for Nursing Action
Elaine Tilka Miller, PhD RN CRRN FAHA FAAN, Editor

The Centers for Medicare & Medicaid Services (CMS) estimate current Medicare spending to be $556 billion or approximately 3.6% of our gross national product (Kaiser Family Foundation, 2010). This is a huge expenditure at a time when our federal government is being forced to seek serious ways to reduce spending. In fact the 2010 Patient Protection and Affordable Care Act calls for a $155 billion decrease in Medicare payments to hospitals over the next decade (Perez, 2011). In addition, countless individual hospitals and long-term-care facilities are already losing millions each year and depend heavily on Medicare payments.

On top of this, the Budget Control Act of 2011 (the so-called “debt deal”) was recently passed. This law calls for a 12-member “super committee” to find new ways to reduce our federal budget by at least $1.5 trillion during the next decade. Although it is unclear where cuts will be made, Medicare spending will likely receive serious scrutiny. It would not be surprising if another $150–$200 billion were cut from Medicare by this super committee.

What does this mean to nursing and, in particular, rehabilitation nursing?

  1. Reducing the cost of care will be mandated by facility and organizational leadership. Nursing has an opportunity to participate in a direct and meaningful way by suggesting cost-reduction ideas and making recommendations for more efficient models of care that can reduce lengths of stay, focus on preventive care measures, enhance the efficacy of medical homes, and maximize the independence of our patients.
  2. "Pay for performance" will be the operational phrase used by CMS and others in health care over the next decade. Nursing needs to play a role in defining pay-for-performance measures. For instance, will these agreed upon measures lead to fewer readmissions, reduced infections, and fewer facility-acquired pressure ulcers? Or are there other measures that are more meaningful, helpful, and evidence-based that should be considered? How will nursing benefit from pay for performance? How will this translate into better patient care, if at all? Nursing must be at the table and not take a back seat as governmental, institutional, and other stakeholders contemplate what should be adopted. Given that we are the largest professional group of healthcare providers, it is imperative that nurses be informed at the national, state, and local level. We must astutely identify and support our nursing champions who can vigorously report on and advocate for those essential care elements that are sometimes forgotten (e.g., quality of life, functional capacity of patients, safety issues).
  3. As part of the healthcare reform process, there will likely be facility-based quality and cost-reduction committees that will be charged with identifying and measuring care behaviors and protocols. Efficiency and better patient outcomes will be connected and measured. In short, how will nursing contribute to more efficiency in caregiving while creating better patient outcomes? New evidence-based measures will need to be invented, reported, and acted upon. Hospitals and other organizations that are able to achieve savings while delivering better outcomes will be the winners. Nursing, which accounts for the majority of all organizational caregiving, will play a pivotal role. Nurses should emphasize their leadership, research, and clinical skills, all of which provide them a unique and important perspective. For instance, the National Institute of Nursing Research publication, “Changing Practice, Changing Lives: 10 Landmark Nursing Research Studies,” describes impressive advances in challenging and costly care issues such as reducing pressure ulcers, self-management of diabetes, blood pressure reduction in African Americans, reducing HIV risk among minority women, and transitional care improving elder outcomes after leaving the hospital.

Most hospitals and long-term-care facilities are already examining their options, care protocols, staffing needs, and organizational efficiencies. Nurses need to become active members of these clinical leadership committees and study the most salient factors affecting length of stay, readmissions within 30 days of discharge, effective staffing patterns, and care coordination policies that need to be evaluated and improved whenever possible (e.g., transfer summaries from unit to unit, facility discharge summaries, gathering data on key benchmarks and barriers and facilitators to their achievement).

Once again, nurses have a unique opportunity to participate in the reshaping of caregiving. Who is better prepared than the more than 2.6 million employed registered nurses in the United States (U.S. Department of Labor, Bureau of Labor Statistics, 2011) to make recommendations and execute positive changes in our care delivery system model?


Kaiser Family Foundation. (2010). Total number of Medicare beneficiaries, 2010. Retrieved August 23, 2011, from www.statehealthfacts.org.

National Institute of Nursing Research. (n.d.). Changing practice, changing lives: 10 landmark nursing research studies. Retrieved August 23, 2011, from www.ninr.nih.gov/NR/rdonlyres/27F3FB10-FE62-4119-9FA9-1140B6950AFF/0/10LandmarkNursingResearchStudies508.pdf.

Perez, K. (2011). Medicare zero: A comprehensive analysis of the impact of health reform and debt deal on Medicare funding of hospitals and strategies of financial survival. Retrieved August 23, 2011, from http://marketing.medeanalytics.com/acton/form/1156/0060:d-0001/0/index.htm.

U. S. Department of Labor, Bureau of Labor Statistics. (2011). Occupational outlook handbook, 2010-11 edition. Retrieved August 23, 2011, from http://www.bls.gov/oco/.