Rethinking Nurse Compensation

Is there a pathway beyond individual reimbursement?

Like many of you, I keep getting updates daily of another brilliant nurse leader joining the Commission for Nurse Reimbursement . It's amazing that they have pulled together a collection of some of the best. I was really excited about the models they were going to present but, I have inquired several times for information on the how and I am met with a broad concept. As someone who prides themselves in providing valuable, innovative advice to my healthcare executives and those purchasing healthcare facilities in effort to make them profitable, I had a genuine desire to learn more. Then, they started asking nurses who are already justifiably not compensated enough to send them money?

Advocacy businesses are not easy to run. I know. I run one. But I would never ask my colleagues, who are being assaulted or the veterans that feed our funnel, to invest in my business efforts. That is the responsibility of their employers. And with the exception of the amazing innovative CEO/CNOs I have met, they won't do it without legislative support.

And unless you have billions of dollars, that can't be bought. It has to be achieved through a concerted effort to outsmart lobbyists and play well in the sandbox full of bees. If I was running an organization that was trying to usurp the most lucrative business in a capitalistic system I wouldn't tell anyone. Not a soul what I was doing until I put legislation on the floor.

But, now we are here and we can't take it back. So, while they continue to give lobbyists time to figure out how to counter all of this, I wanted to give some folks practical things you can do right now to make a difference in your healthcare system. For free. :)

Please don't confuse this with the fact that I don't recognize that the value of nursing care is often overshadowed by outdated compensation models that bundle nursing services into broader categories like room and board. How many nurses in the Commission are still at the bedside, wiping butts and getting yelled at by frustrated patients? Well, I am. Not because I have to, but because how do I say I am nurse advocate concerned about staffing if I don't step down of my LinkedIn ledge and staff?

Even at my measly 1 shift a month (mainly because that's all I can handle), I see it and while shifting to a model where nurses are directly reimbursed for their care would be incredible, this approach is fraught with complexities and obstacles, making it unlikely to succeed in the American healthcare system.

Instead, I think we must explore alternative models that recognize and reward the critical role nurses play without upending the current system. (Which if you haven't noticed is unstable enough).

The Challenges of Direct Reimbursement for Nurses

The idea of reimbursing nurses directly for their care has some undeniable positives. It could elevate the perceived value of nursing, incentivize high-quality care, and enhance professional autonomy. However, the hurdles are significant:

1. Systemic Disruption: The current payment system, under which nursing care is bundled with other services, is deeply ingrained in how the Centers for Medicare & Medicaid Services (CMS) operates. Separating nursing care from these bundles would require an overhaul of billing structures, adding administrative complexity and potential inefficiencies. Not impossible, but without a really strong tech partner and some support from CMS, it's going to be a super heavy lift.

2. Resistance from Powerful Lobbyists: The current system is supported by influential healthcare lobbyists, including those representing hospitals, insurance companies, and large healthcare organizations. These groups benefit from the status quo and would likely oppose any changes that could disrupt their revenue streams or increase administrative burdens. Who is ready to go to law school?

3. Complexity and Costs: Identifying and valuing nursing care separately would be an enormous task, requiring new coding, billing, and documentation systems. There’s also the risk of increased healthcare costs, making an already expensive system even less accessible. We can't even get people to document their workplace violence incidents, do you think overburdened nurse managers are going to participate in this? I think we are better at tackling one thing at a time, collectively. That's been the point of nursing organizations, but now they are endorsing candidates so that's out.

Exploring Alternative Compensation Models

Given the challenges of individual reimbursement, we must consider more feasible alternatives that still elevate the role and compensation of nurses. Here are some models that could be more effective:

1. Value-Based Care Models:

- Shared Savings Programs: Integrate nurses into value-based initiatives, where they share in financial incentives tied to patient outcomes and cost savings. Provide great care, get a bonus. Which requires CNOs to help hold CEOs accountable to not pocket extra revenue. Want to work less as a CNO? Pay your staff more. Distribute your bonus to a unit with great quality metrics this Christmas and see what happens.

- Team-Based Compensation: Reward multidisciplinary teams, including nurses, based on collective performance metrics, promoting collaboration and recognizing nursing contributions. This would be step one to a new model, figure out what is bundled in nursing care and how. Since Nurses do the majority of care at the bedside now, how do you even separate the two. One of the questions I have for Commission members, if you can answer it would be helpful to me and the other leaders who are sitting back wondering how.

2. Enhanced Salary Models with Performance Bonuses:

- Salary Plus Bonuses: Combine a stable salary with performance-based bonuses tied to patient outcomes and quality metrics. Again, back to the bonuses that require giving up yachts. Have you ever been on yacht? That's hard to give up. (I am applying for Law school as I write this.)

- Pay-for-Performance (P4P): Link a portion of nurse compensation to specific quality and efficiency metrics, incentivizing improvements in patient care. This is super easy to do if your nurse managers are efficiently managing budgets. Another great piece of technology that would give you the wiggle room to do this is In-House Health . They can also help look at other metrics like complexity of patients. Honestly, with a 1:5 ROI, this is a great fit for CNOs who want to look at what at P4P would look like. Do the ground work with this tech, get staffing fixed then have the data to make an informed decision. Oh, and it makes you money. You are welcome. Reach out to Zenith Tillemann-Dick for more information.

3. Professional Advancement Models:

- Clinical Ladder Programs: Compensate nurses based on their level of expertise and contributions, offering pathways for professional and financial advancement. This has always been around but the 3 cent difference is really not enough. 5 dollars, 10 dollars. Can you afford it? Yeah, let us show you how.

- Advanced Practice Roles: Encourage specialty certifications and advanced roles, with corresponding increases in compensation. Take your charge nurses out of the numbers, train them well and equip them to do their jobs. Pay them well, let them learn how to be leaders and help save your floors from catching fire all the time. Hire based on quality of the person not quality of the skill. Skills can be enhanced, leadership and humility and professionalism are hard to find. Need help hiring to meet your company culture? AudienceLink Ltd. is a great option. They are cheaper than Indeed and do a way better job. Also, they have a nurse wellness and retention program from hire made by Jennifer Johnson . Its brilliant. Contact Nick Bussey for more information. They will be at the Nursing Innovation pavilion at health. Kudos to Rebecca Love RN, MSN, FIEL for pulling together actionable ways to help save your systems NOW!

4. Global Budgeting with Enhanced Nursing Roles:

- Global Budgets: Allocate fixed budgets for hospitals, with a focus on enhancing nursing roles and compensation within these budgets. Oh that one is tricky. Causes lots of accountability. No private planes!

- Nurse-Led Clinics: Expand nurse-led clinics, particularly in underserved areas, allowing nurses to take on more autonomous roles with appropriate compensation. Don't close your rural hospitals, turn them into behavioral health centers. I know some great people. Use them as training areas. Run your diagnostics and out patient services in them. Put a nursing simulation lab in them. Turn them into a school that funnels you staff. Lot's of ideas: Just ask.

5. Bundled Payments with Nursing-Specific Metrics:

- Bundled Payment Systems: Develop nursing-specific metrics within bundled payments, ensuring that nursing care is recognized and rewarded as part of comprehensive care episodes.

- Inclusion in ACOs: Integrate nursing care into Accountable Care Organizations (ACOs), ensuring nurses are included in shared savings models.

6. Strengthening Nursing Leadership:

- Empowering CNOs: Strengthen the role of Chief Nursing Officers (CNOs) to negotiate better compensation and working conditions for nurses. Nursing leaders have been shoved aside in the board room when in reality, without a CNO you can't operate. So, they have an ethical obligation to provide safe workplaces for their staff by the State Practice Acts as well as create safe patient care. That requires physical responsibility that overrides the CFO's decision, and the CEO's unless the CEO is a nurse. They violate their ethical and legal responsibilities for patients and their employees, guess what, they close your hospital. Who wants to take time off the golf game to look for another job? Not me.

- Nursing Leadership in Healthcare Strategy: Elevate nurse leaders to key roles in healthcare strategy and decision-making, ensuring that nursing care is a priority in organizational planning. Teach them the business of healthcare so they don't have to ask their colleagues for money to create change.

Nurses: Learn the truth about the American Healthcare system, don't just stand there and complain. You have an ethical responsibility to stand up for your patients. Take some time off of TIKTOk and watch a free lecture on youtube about Constitutional Law and come back to me and tell me what you learned about coercion.

Reforming nurse compensation in a way that truly recognizes the value of their care requires a balanced approach that respects the complexities of the current system while pushing for meaningful change. By exploring these alternative models, we can begin to create a more equitable and effective system that rewards nurses for the critical role they play in our healthcare system—without the need for a disruptive overhaul that faces steep opposition from powerful lobbyists. The path forward involves incremental steps that build on existing structures, ensuring that nurses are compensated fairly and recognized as integral to the delivery of high-quality care.