The Quintuple Aim

Last week I gave a talk titled ‘Challenges in Long-Term Care and Skilled Nursing Facilities’ at the Commission for Nurse Reimbursement’s Inaugural Legislative Summit in Washington DC.?

In addition to highlighting the systemic challenges facing LTC & SNFs, and how nurse reimbursement will help address them, I spoke about the historical context that led to the undervaluation of nursing (it’s outlined below and it’s a stunning miscarriage of justice).?

During the Q&A section that followed I off-handedly and somewhat jokingly referred to gender pay equity as part of the “Quintuple Aim”.

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A quick note on definitions:?

• Gender pay ‘equality’ refers to people being paid the same amount for the same work regardless of gender, race, sexuality, etc. Gender pay “equity” focuses on ensuring fairness in compensation for all, considering factors beyond the scope of equal pay for equal work. As an example, in the NFL left tackles and quarterbacks are not paid equally, but there is equity in their pay in relation to their contribution to the team — and one cannot succeed without the other.?
• For those not in healthcare, the ‘Triple Aim’ first advanced by Don Berwick , MD, MPP, in 2008, refers to simultaneously pursuing three aims in healthcare: 1) improving the experience of care, 2) improving the health of populations, and 3) reducing per capita costs of health care. In a 2014 paper in the Annals of Family Medicine, Thomas Bodenheimer, MD, and Christine Sinsky , MD, advanced the idea of the ‘Quadruple Aim” adding 4) the goal of improving the work life of healthcare providers, including clinicians and staff (note, the ‘Quintuple Aim’ was something I thought I’d just coined on the spot (I did not*)].

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After the Summit I was thinking back on the phrase Quintuple Aim and how it actually makes perfect sense to have gender pay equity as the fifth column in the structure of the healthcare system we all actually want.?

Good healthcare is good human care, and gender pay equity is certainly part of the equation of good human care.

Further, gender pay equity both buttresses and advances each element of the Quadruple Aim.

The History of Nurse Reimbursement

Before we get into how that all works, here’s the story of how we’ve arrived at our current moment of gross pay inequity as told by the Commission’s Founder and Co-Chair, Rebecca Love RN, MSN, FIEL , on this episode of NurseDot Podcast from Nurse.com :

“All right, so let me start you back in time almost over a hundred years ago and you probably recall in the early 1900s, women were fighting for the right to vote and nurses tended to stay out of that fight.

They weren't behind 100% fighting for women's right to vote in this country until 1919 when the American Nurses Union at the time organized what would be the largest march to support the women's suffrage movement in the history of the country.

So 1919, American Nurses Union finally gets behind the idea of women's right to vote and in 1920, the 19th Amendment is passed, women's right to vote happens, women obtain the right to vote in this country.

Now over the 1920s, by allowing women the right to vote, nursing quickly becomes the greatest economic vehicle for women's financial independence in the history of the world.

Nurses at that time all ran their own independent practices.

They all had their own ability to hire clients, bill for their services, and at that time, hospitals were this place of deplorable conditions.

Only the most destitute would seek care there.

And then surgery started to get developed into hospitals.

Private families started to bring private duty nurses in to provide care in these hospitals.

Hospitals started to see that outcomes were getting better

So [hospitals] started to bring nurses in to get better outcomes for their patients.

What they saw is that healthcare across the entire hospital system got better and what took place was at that time that bills would be issued, you would clearly see demarcated on all bills from hospitals in the 1920s, a clear line that demarcated nursing services

So nurses billed for their services in the 1920s.

This was common practice.

Now as you can imagine, as nurses could bill for their practices, hospitals run by men, doctors being men, started to see economic competition by nurses to the hospital model.

They started to feel women had too much power.

According to the expert researcher, Donna Deer, she said hospitals wanted to keep nurses as far away from the money as possible.

So in the 1930s, when they started to invent national insurance to pay for healthcare, these doctors, these hospital administrators, men, started to look for models which they could pay for nursing services but not necessarily break them out as a billable service.

They turned to hotels, looked and saw that maids were rolled into room rates and then they rolled nurses into room rates in the 1930s.

Why Nurse Reimbursement?

Considering the years of training nurses must go through to enter their profession this comparison is certainly not apt, and the broader implications of the decision to roll nursing into the room rate of hospitals has created a divide in payment to nurses that is not even remotely commensurate with the impact that nurses and good nursing has on patient care, patient outcomes, and cost savings to the system.

And that is an absolute travesty for our healthcare system, for our patients, and for our nurses who are being done wrong every day we perpetuate this misguided system.

Nurse reimbursement solves this, and even better it helps achieve the other aims.?

For if we’re interested in 1) ‘improving the experience of care’, we do that by properly rewarding the caregivers that are most closely involved in the experience of care, 2) ‘improving the health of populations’, we do that by recognizing the importance of those delivering care at the bedside, 3) ‘improving the work life of providers’, we do that by paying them for the services they provide, just like we do with every other group of healthcare professionals, and 4) reducing per capita costs of healthcare, we do that by reimbursing nurses.

You may have noticed I switched the order of aims 3) and 4) because reducing per capita costs needs a bit of unpacking.

What Will Nurse Reimbursement do to Costs?

If nurses are no longer a cost center to hospitals and to nursing homes but rather a revenue generative element of those organizations, we will unlock the ability of facilities to hire more nurses. We will have better care, and we will save money by avoiding unnecessary costs.

From my perch in healthcare technology, and in the SNF sector, I see massive inefficiency in resource allocation — a systems problem, not a people problem — that costs our tax payers untold billions of dollars.

Every time a SNF patient is admitted to the hospital it costs between $15,000-$30,000.?

This happens to more than one in every five patients admitted into SNFs.

Even more troubling is that it happens all the time for conditions that could and would be treated in the SNF if only they were staffed properly and SNF providers had the tools and resources to deliver optimal care — both for their patients and themselves.

In April of this year the Centers for Medicare and Medicaid Services announced its final ruling on SNF staffing minimums. One of the rules increases the required minimum of Registered Nurse hours on-site in SNFs from eight hours a day to 24 hours a day.?

We absolutely need more nurses in SNFs but according to CLA’s Cost Comparison and Industry Trends Report SNFs had a -0.6% operating margin in 2022. SNF leadership needs the tools to resource their staff properly, they don’t need nearly impossible-to-meet- mandates and more chances to be fined. Adding another cost to the industry is not going to solve the crisis of care for our most vulnerable patients — it’s going to exacerbate it.

Nurse reimbursement solves this. If nurses are paid for the services they perform, they become revenue-generative to SNFs and SNFs are accordingly incentivized to hire more nurses.?

The same is true in hospitals. A 2021 study of 116 New York hospitals with Medicare claims data by Karen Lasater PhD, RN, et.al estimated that if patient to nurse ratio were reduced from 6.3 patients for every nurse to 4 patients for every nurse 4,370 lives and $720m would? saved, due to shorter lengths of stays, and avoided readmissions.

The Quintuple Aim Hits the Target

Nurse staffing mandates make sense but only if we pay nurses for their work. And if we pay nurses for their work we won’t need staffing mandates. In fact, there’s also no shortage of nurses. More than one million nurses are currently not working as nurses and in a 2023 study close to a third of nurses nationwide say they are likely to leave the profession for another career

This is because of burnout and a lack of proper recognition of the service nurses provide.?

Staffing limits are all stick no carrot. We must be mindful of adding a carrot to the stick if we want our healthcare systems and facilities to act as we all want them to. That’s how we can achieve the Quintuple Aim.?

*The Quintuple Aim appears to have first been identified in November of 2021 Dipti Itchhaporia, MD, FACC in Health Equity, Health Outcomes and the Economy, and is described as “[incorporating] health equity as another key element necessary to truly achieving improved patient care, outcomes, and costs” — and while the description in that paper is more centered around the patient side of equity gender pay equity certainly falls squarely in the purview of health equity.??

This article represents my personal opinions but I do want to express my gratitude to the Commission for Nurse Reimbursement for inviting me to join its critical mission and to each of the Commissioners for all of their hard work. You can see all the presentations from the Legislative Summit at our YouTube page here: https://lnkd.in/gRJgZ5_k

Rebecca Love RN, MSN, FIEL Sharon Pearce Melissa Mills, RN, BSN, MHA Robert Longyear Ajay Kumar Gupta Jane Jeppson Mirini Kim DNP, RN, CPNP-PC Shannon Lunn, RN, CRN-BC, CNMAP John Welton, PhD, RN PK Scheerle, RN Renee Ellmers, BSN, RN Rachel E. Start RN, MSN, NEA-BC, FAAN Stephanie Witwer, PhD, RN, NEA-BC, FAAN Cynthia L Murray BN-RN, AMB-BC, LNC Katie Davis, MS, RN, AGACNP-BC