Higher Nurse Staffing Levels May Mean Fewer CMS Penalties

Norra MacReady

October 10, 2013

More nurses mean lower odds of hospital readmission, and that translates into cost savings for hospitals as well as better patient care, a new study suggests.

Since October 1, 2012, as part of the Patient Protection and Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) has been reducing payments to hospitals that report excessive 30-day readmission rates among Medicare patients for acute myocardial infarction, heart failure, or pneumonia, note Matthew D. McHugh, RN, PhD, JD, MPH, from the School of Nursing and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, and coauthors.

This effort is known as the Hospital Readmissions Reduction Program (HRRP) and was developed to reduce the rate of preventable readmissions, which costs CMS an estimated $15 billion annually, the authors note in an article published in the October issue of Health Affairs. The HRRP allows CMS to reduce hospital diagnosis-related group reimbursement by up to 1%.

"Among a national sample of hospitals, we found that even after closely matching on hospital and patient population characteristics, hospitals with better registered nurse staffing levels were significantly less likely to be penalized under the CMS Hospital Readmissions Reduction Program than otherwise similar hospitals that were less well staffed," the authors write.

Dr. McHugh and colleagues examined the relationship between registered nurse staffing levels and hospital performance under the HRRP by comparing HRRP penalties among well-staffed hospitals with those of hospitals with similar characteristics but lower staffing levels. They used information from a variety of sources, including the American Hospital Association, the Medicare Provider Analysis and Review, and Medicare Beneficiary Annual Summary files to match hospitals on characteristics such as size, teaching intensity (ratio of physician residents or fellows to beds), operating margins, community market share, patient demographics, and other structural and patient-mix characteristics that might account for variations in hospital staffing levels or readmission rates. In addition, they based their analysis on a risk-standardized readmission rate to ensure an "apples-to-apples" comparison.

Overall higher nurse staffing levels were associated with a 25% reduction in risk (odds ratio ([OR] of 0.75) for receiving some type of penalty under the HRRP compared with lower staffing levels. The OR was the same whether the authors assumed that all bias was removed from the comparison (95% confidence interval [CI], 0.64 - 0.89) or when they added controls for residual covariate imbalance (95% CI, 0.63 - 0.88).

In a comparison of fully penalized hospitals vs all other hospitals, higher nurse staffing ratios were associated with an OR of 0.59 that a hospital would be hit with the maximum penalty allowed under the HRRP (95% CI, 0.44 - 0.92).

"In our primary analyses and all of the alternative specifications of our models, we consistently saw that hospitals with higher nurse staffing levels had significantly lower odds of being penalized than similar hospitals with lower nurse staffing levels," the authors write. Each additional nurse hour per adjusted patient day was associated with a 10% decrease in the odds of being penalized.

In a supplementary analysis, the authors found that "a greater proportion of patients in better-staffed hospitals rated their hospital highly and would recommend it to friends and family — factors associated with readmissions and better staffing."

"Our findings highlight a component of the hospital care delivery system that can be targeted to limit hospitals' exposure to readmissions penalties while improving patient outcomes," they conclude. "By focusing on a system factor such as nurse staffing, administrators may be able to address multiple quality issues while reducing their likelihood of penalty for excess readmissions."

The authors have disclosed no relevant financial relationships.

Health Affairs. 2013;32:1740-1747. Abstract

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