Invisible economics of nursing: analysis of a hospital bill through a Foucauldian perspective

Health care is expensive and becoming increasingly more so. USA spends significantly more of its gross domestic product (GDP) on health care compared with other countries. In 2009, USA spent 17.4% of GDP on health care expenses, while the second largest spender, the Netherlands, spent 12% of GDP (OECD, 2011).The current state of health care spending in USA is unsustainable and threatens the fiscal well-being of the nation (Antos et al., 2012). Nearly a third of all USA health care expenditures are spent in the acute care hospital setting. In 2012, it is estimated that approximately $880 billion was spent in hospitals (Kocher & Emanuel, 2012). Nursing care services are the most intensely used hospital services by acute hospital inpatients yet are poorly economically measured (Knauf et al., 2006). After a patient is discharged from a hospital, he or she receives a hospital bill that is intended to represent the cost of the services provided to him or her during that particular hospital visit. The line items on the hospital bill function to capture the value of the care provided throughout the duration of the inpatient stay. For example, each physician or specialist visit is billed at a particular rate depending on the diagnosis-related group (DRG) under which the patient is admitted. Allied health care professionals who are not employed by the hospital, such as physical and occupational therapists, also independently bill for the time spent providing services to the patient. Nurses are an anomaly in the current inpatient billing system. Rather than bill for the actual services provided to the patient or the amount of time spent providing nursing care, the cost of nursing is embedded into the line item for room and board, which is the same fixed cost for every patient receiving the same level of care within a particular institution. In other words, all patients cared for on a given unit are billed the same room and board charge regardless of the actual amount of nursing care the patient utilized during that hospitalization. Historically in USA, the majority of nursing care was provided in a patient’s home. Nurses billed patients directly for services. However, when medical advances in the early 20th century caused more patients to seek care in the hospital setting, nurses followed patients from the home into the hospital (Welton & Harris, 2007). This created a competitive economic relationship among hospitals, physicians, and nurses. Nurses became hired as employees of the hospital, thus resulting in the billing of nursing services as hospital room and board (Welton & Harris, 2007). Hospital staff nurses’ lack of visibility, as an economically valued provider, is largely a product of the historical impact of hiring nurses as employees of the hospital. Consequently, nursing’s lack of representation on the hospital bill is problematic for the perception of nurses as financially valuable health care providers. The loss of economic visibility of nursing is problematic for multiple reasons. Hospitals generally consider nursing an expense rather than revenue generating because hospitals are not directly compensated for nursing care in the same way they are compensated for physician or other allied health services. Therefore, hospitals are motivated to cut costs by rationing nursing care rather than investing in aligning nursing care intensity with individual patient Correspondence: Ms Karen B. Lasater, Doctoral Fellow, University of Pennsylvania, Claire M. Fagin Hall, 418 Curie Boulevard, Philadelphia, PA 19104-4217, USA. Tel. (+1) 413552 8143; fax: (+1) 215573 2062; e-mail: karenbl@nursing.upenn.edu D iague doi: 10.1111/nup.12040