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Congressional and Veterans Affairs (VA) leaders have recommended the VA become more of a purchaser than a provider of health care. Fee-for-service Medicare provides an example of how purchased care differs from the VA’s directly provided care. Using established indicators of overly intensive end-of-life care, we compared the quality of care provided through the two systems to veterans dying of cancer in fiscal years 2010–14. The Medicare-reliant veterans were significantly more likely to receive high-intensity care, in the form of chemotherapy, hospital stays, admission to the intensive care unit, more days spent in the hospital, and death in the hospital. However, they were significantly less likely than VA-reliant patients to have multiple emergency department visits. Higher-intensity end-of-life care may be driven by financial incentives present in fee-for-service Medicare but not in the VA’s integrated system. To avoid putting VA-reliant veterans at risk of receiving lower-quality care, VA care-purcha...

Safety-net hospitals rely on disproportionate-share hospital (DSH) payments to help cover uncompensated care costs and underpayments by Medicaid (known as Medicaid shortfalls). The Affordable Care Act (ACA) anticipates that insurance expansion will increase safety-net hospitals' revenues and will reduce DSH payments accordingly. We examined the impact of the ACA's Medicaid DSH reductions on California public hospitals' financial stability by estimating how total DSH costs (uncompensated care costs and Medicaid shortfalls) will change as a result of insurance expansion and the offsetting DSH reductions. Decreases in uncompensated care costs resulting from the ACA insurance expansion may not match the act's DSH reductions because of the high number of people who will remain uninsured, low Medicaid reimbursement rates, and medical cost inflation. Taking these three factors into account, we estimate that California public hospitals' total DSH costs will increase from $2.044 billion in 2010 to $2.363-$2.503 billion in 2019, with unmet DSH costs of $1.381-$1.537 billion.

Discussions of hospital quality, efficiency, and nursing care often taken place independent of one another. Activities to assure the adequacy and performance of hospital nursing, improve quality, and achieve effective control of hospital costs need to be harmonized. Nurses are critical to the delivery of high-quality, efficient care. Lessons from Magnet program hospitals and hospitals implementing front-line staff–driven performance improvement programs such as Transforming Care at the Bedside illustrate how nurses and staff, supported by leadership, can be actively involved in improving both the quality and the efficiency of hospital care.

We construct national estimates of the cost of increasing hospital nurse staffing and associated reductions in days, deaths, and adverse outcomes. Raising the proportion of nursing hours provided by registered nurses (RNs) without increasing total nursing hours is associated with a net reduction in costs. Increasing nursing hours, with or without increasing the proportion of hours provided by RNs, reduces days, adverse outcomes, and patient deaths, but with a net increase in hospital costs of 1.5 percent or less at the staffing levels modeled. Whether or not staffing should be increased depends on the value patients and payers assign to avoided deaths and complications.

Hospitals, nurses, the media, Congress, and the private sector are increasingly concerned about shortages of registered nurses (RNs) and the impact on safety and quality of patient care. Findings from a growing number of studies provide evidence of a relationship between hospital nurse staffing and adverse outcomes experienced by medical and surgical patients. These findings have policy implications for strengthening the nursing profession, monitoring the quality of hospital care associated with nursing, and improving the relationship between hospitals and the nursing profession.