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May 17, 1995, Vol 273, No. 19 >
ARTICLE | May 17, 1995

The Case for Policy Change FREE

Linda H. Aiken, PhD, RN; Marni E. Gwyther
[+] Author Affiliations

Reprint requests to Center for Health Services and Policy Research, School of Nursing, University of Pennsylvania, 420 Guardian Dr, Philadelphia, PA 19104-6096 (Dr Aiken).


JAMA. 1995;273(19):1528-1532. doi:10.1001/jama.1995.03520430064040
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Objectives.  —To determine the magnitude and distribution of US Medicare funding for nursing education and to assess the extent to which Medicare funding contributes to meeting national health care workforce priorities.

Data Sources.  —Medicare Hospital Cost Report Information System, American Hospital Association Annual Survey of Hospitals, and National League for Nursing national surveys of schools of nursing.

Data Analysis.  —Using hospital identifiers, data from three data sets were merged and analyzed to estimate percentage distributions of Medicare funding according to types of educational programs, hospital characteristics, and student enrollment.

Results.  —Fifteen percent of direct Medicare graduate medical education funding goes to hospitals for the training of nurses and paramedical personnel. Totaling approximately $174 million in 1991, 71% of these funds went to hospitals for nursing education costs. Most of the nation's teaching hospitals (289 of 381 Council of Teaching Hospitals member hospitals) and nurse education programs (1112 of 1484) do not qualify under existing policies for Medicare nursing education reimbursement. Sixty-six percent of Medicare nurse training funds, totaling $114 million in 1991, went to 145 hospitals operating diploma nursing programs; these programs produce less than 10% of nurse graduates. Three states (Pennsylvania, New Jersey, and Ohio) received nearly one half (48%) of the $114 million for diploma nursing education.

Conclusions.  —Medicare is the largest single source of federal support for nursing education. Yet, the majority of Medicare nursing education funding goes to hospitals affiliated with an increasingly smaller, idiosyncratic subset of nurse training programs. Unlike graduate medical education, Medicare supports primarily preprofessional education in nursing. Graduate education, including the preparation of nurse practitioners, does not generally qualify for reimbursement. Medicare reimbursement for nursing education must be retargeted.(JAMA. 1995;273:1528-1532)

REFERENCES

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Feldstein PJ. Health Care Economics . New York, NY: John Wiley & Sons; 1979;.
2 +
Statistical Abstract of the United States: 1993 . 113th ed. Washington, DC: US Bureau of the Census; 1993;.
3 +
The Registered Nurse Population: Findings From the National Sample Survey of Registered Nurses, March 1992 . Washington, DC: US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing; 1994;.
4 +
Final Report: Registered Nurse Chartbook . Washington, DC: Office of the Assistant Secretary for Health; 1994;.
5 +
The Registered Nurse Population: Findings From the National Sample Survey of Registered Nurses, March 1988 . Washington, DC: US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing; 1990;.
6 +
Berliner HS, Kovner CT, Goldman F, Balinksky W, Rosado T, Cook S. The Supply and Demand for Health Workers in New York City: 1995-1997 . New York, NY: New School for Social Research; October 1994;.
7 +
APM Management Consultants. The Effect of Hospital Restructuring on Nursing: Executive Summary . Chicago, Ill: APM Management Consultants; 1994;.
8 +
Seventh Report to the President and Congress on the Status of Health Personnel in the United States . Washington, DC: US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration; 1990;.
9 +
Health Personnel in the United States: Eighth Report to Congress, 1991 . Washington, DC: US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration; 1992;.
10 +
Pew Health Professions Commission. Health Professions Education for the Future: Schools in Service to the Nation . San Francisco, Calif: Pew Health Professions Commission; 1993;.
11 +
Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (Health Technology Case Study 37) . Washington, DC: Office of Technology Assessment; 1986;.
12 +
Ganem JL, Krakower JK, Beran RL.  Review of US medical school finances, 1992-1993. JAMA . 1994;; 272:705-711.
13 +
Institute of Medicine. Report of a Study of the Costs of Education in the Health Professions . Washington, DC: National Academy of Sciences; 1974;.
14 +
National Center for Education Statistics, US Dept of Education. Current Funds Revenues and Expenditures of Institutions of Higher Education: Fiscal Years 1984-1992 . Washington, DC: National Center for Education Statistics, US Dept of Education; 1994:8, 10.
15 +
Health Care Financing Administration.  Medicare program: payment for nursing and allied health education. Federal Register . (September 22) , 1992;; 57:43659-43673.
16 +
National League for Nursing, Division of Research. Nursing Data Review: 1994 . New York, NY: National League for Nursing Press; 1994;.
17 +
National League for Nursing, Division of Research. Nursing Data Review: 1981 . New York, NY: National League for Nursing Press; 1981;.
18 +
Yett DE. An Economic Analysis of Nurse Shortage . Lexington, Mass: Lexington Books; 1975;.
19 +
American Hospital Association. AHA Hospital Statistics, 1972 . Chicago, Ill: American Hospital Association; 1972;.
20 +
American Hospital Association. AHA Hospital Statistics, 1994-95 Edition . Chicago, Ill: American Hospital Association; 1994;.
21 +
Report to the Congress on Nursing and Other Nonphysician Health Professions Educational Programs Reimbursed Under Medicare . Washington, DC: US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions; 1988;.
22 +
American Association of Nurse Anesthetists. Statement of the American Association of Nurse Anesthetists before the Physician Payment Review Commission regarding Issues to be Addressed in PPRC's 1994 Annual Report (testimony presented by Linda L. Callahan, AANA President); November 29, 1993.
23 +
National League for Nursing, Division of Research. State Approved Schools of Nursing: RN, 1993 . New York, NY: National League for Nursing Press; 1993;.
24 +
Mullan F, Rivo ML, Politzer RM.  Doctors, dollars, and determination: making physician workforce policy. Health Aff (Millwood) . 1993;;12( (suppl) ): 138-151.
25 +
Aiken LH, Salmon ME.  Health care work force priorities: what nursing should do now. Inquiry . 1994;;31:318-329.
26 +
Clawson DK, Osterweis M, eds. The Roles of Physician Assistants and Nurse Practitioners in Primary Care . Washington, DC: Association of Academic Health Centers; 1993;.
27 +
Goldmark J. Nursing and Nursing Education in the United States: Report of the Committee for the Study of Nursing Education . New York, NY: Garland; 1984;. Reprint of 1922 publication.
28 +
Flexner A. Medical Educations in the United States and Canada . New York, NY: Carnegie Foundation; 1910;.
29 +
Fagin C. Nursing Leadership: Global Strategies . New York, NY: National League for Nursing; 1990;. Publication 41-2349.
30 +
Nursing in the World: The Facts, Needs, and Prospects . 3rd ed. Tokyo, Japan: The International Nursing Foundation of Japan; 1993;.

Figures

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Interactive Graphics

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Feldstein PJ. Health Care Economics . New York, NY: John Wiley & Sons; 1979;.
2 +
Statistical Abstract of the United States: 1993 . 113th ed. Washington, DC: US Bureau of the Census; 1993;.
3 +
The Registered Nurse Population: Findings From the National Sample Survey of Registered Nurses, March 1992 . Washington, DC: US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing; 1994;.
4 +
Final Report: Registered Nurse Chartbook . Washington, DC: Office of the Assistant Secretary for Health; 1994;.
5 +
The Registered Nurse Population: Findings From the National Sample Survey of Registered Nurses, March 1988 . Washington, DC: US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing; 1990;.
6 +
Berliner HS, Kovner CT, Goldman F, Balinksky W, Rosado T, Cook S. The Supply and Demand for Health Workers in New York City: 1995-1997 . New York, NY: New School for Social Research; October 1994;.
7 +
APM Management Consultants. The Effect of Hospital Restructuring on Nursing: Executive Summary . Chicago, Ill: APM Management Consultants; 1994;.
8 +
Seventh Report to the President and Congress on the Status of Health Personnel in the United States . Washington, DC: US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration; 1990;.
9 +
Health Personnel in the United States: Eighth Report to Congress, 1991 . Washington, DC: US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration; 1992;.
10 +
Pew Health Professions Commission. Health Professions Education for the Future: Schools in Service to the Nation . San Francisco, Calif: Pew Health Professions Commission; 1993;.
11 +
Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (Health Technology Case Study 37) . Washington, DC: Office of Technology Assessment; 1986;.
12 +
Ganem JL, Krakower JK, Beran RL.  Review of US medical school finances, 1992-1993. JAMA . 1994;; 272:705-711.
13 +
Institute of Medicine. Report of a Study of the Costs of Education in the Health Professions . Washington, DC: National Academy of Sciences; 1974;.
14 +
National Center for Education Statistics, US Dept of Education. Current Funds Revenues and Expenditures of Institutions of Higher Education: Fiscal Years 1984-1992 . Washington, DC: National Center for Education Statistics, US Dept of Education; 1994:8, 10.
15 +
Health Care Financing Administration.  Medicare program: payment for nursing and allied health education. Federal Register . (September 22) , 1992;; 57:43659-43673.
16 +
National League for Nursing, Division of Research. Nursing Data Review: 1994 . New York, NY: National League for Nursing Press; 1994;.
17 +
National League for Nursing, Division of Research. Nursing Data Review: 1981 . New York, NY: National League for Nursing Press; 1981;.
18 +
Yett DE. An Economic Analysis of Nurse Shortage . Lexington, Mass: Lexington Books; 1975;.
19 +
American Hospital Association. AHA Hospital Statistics, 1972 . Chicago, Ill: American Hospital Association; 1972;.
20 +
American Hospital Association. AHA Hospital Statistics, 1994-95 Edition . Chicago, Ill: American Hospital Association; 1994;.
21 +
Report to the Congress on Nursing and Other Nonphysician Health Professions Educational Programs Reimbursed Under Medicare . Washington, DC: US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions; 1988;.
22 +
American Association of Nurse Anesthetists. Statement of the American Association of Nurse Anesthetists before the Physician Payment Review Commission regarding Issues to be Addressed in PPRC's 1994 Annual Report (testimony presented by Linda L. Callahan, AANA President); November 29, 1993.
23 +
National League for Nursing, Division of Research. State Approved Schools of Nursing: RN, 1993 . New York, NY: National League for Nursing Press; 1993;.
24 +
Mullan F, Rivo ML, Politzer RM.  Doctors, dollars, and determination: making physician workforce policy. Health Aff (Millwood) . 1993;;12( (suppl) ): 138-151.
25 +
Aiken LH, Salmon ME.  Health care work force priorities: what nursing should do now. Inquiry . 1994;;31:318-329.
26 +
Clawson DK, Osterweis M, eds. The Roles of Physician Assistants and Nurse Practitioners in Primary Care . Washington, DC: Association of Academic Health Centers; 1993;.
27 +
Goldmark J. Nursing and Nursing Education in the United States: Report of the Committee for the Study of Nursing Education . New York, NY: Garland; 1984;. Reprint of 1922 publication.
28 +
Flexner A. Medical Educations in the United States and Canada . New York, NY: Carnegie Foundation; 1910;.
29 +
Fagin C. Nursing Leadership: Global Strategies . New York, NY: National League for Nursing; 1990;. Publication 41-2349.
30 +
Nursing in the World: The Facts, Needs, and Prospects . 3rd ed. Tokyo, Japan: The International Nursing Foundation of Japan; 1993;.

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