Outcomes/Effectiveness Research

Mandated increases in nurse staffing levels unevenly affect uncompensated care growth rates in California hospitals

In 1999, California became the first State to pass mandated minimum nurse staffing requirements for certain hospital patient care units. For example, in 2006, one nurse was required for every five patients for medical-surgical areas. These requirements boost a hospital's operating costs, especially in hospitals that were understaffed relative to the mandated ratios prior to the legislation, thus potentially reducing the amount of uncompensated care hospitals provide. However, a new study found that the new requirements had an inconsistent effect on hospitals' provision of uncompensated care (sum of charity care plus bad debt).

The study included 228 short-term, general hospitals in California over the period 1999 to 2006. Using the nurse staffing levels in the preregulation period, the researchers divided the hospitals into quartiles, reflecting the lowest to highest preregulation nurse staffing levels. Growth rates in uncompensated care were lower for hospitals in the lowest three staffing quartiles compared with those in the highest quartile. However, results were statistically significant only for county and for-profit hospitals in quartiles 1 and 3.

Uncompensated care averaged 5 to 6 percent of total operating expenses over the study period, and was similar across all of the staffing quartiles, as was the average growth rate. The researchers concluded that their findings did not show broad reductions in uncompensated care following the implementation of minimum nurse staffing legislation in California. However, apparent reductions among county and for-profit hospitals suggest the need for caution when considering such legislation and other quality improvements that directly increase operating expenses, and therefore threaten hospital profitability. This study was supported by the Agency for Healthcare Research and Quality (HS10153).

See "The effect on minimum nurse staffing legislation on uncompensated care provided by California hospitals," by Kristin L. Reiter, Ph.D., David W. Harless, Ph.D., George H. Pink, Ph.D., and others in Medical Care Research and Review, 2010 (epub ahead of print).

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