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A home health nurse visits an elderly man on a ventilator and takesn time to teach the patient's wife about his medications. She gives the family the help they need, but the visit will cost her agency more than Medicare will pay-without counting the time it will take to do the OASIS reporting!! Her next appointment is 50 miles away. If only her mileage reimbursement kept pace with gasoline prices. I love my job, she reminds herself, but I wish I made the rules.


In a very real sense, she can. The federal government is the largest payer for most visiting nurse associations (VNAs). When payment systems do not reflect what happens in the clinical setting, VNAs get shortchanged. This compromises their ability to care for patients and to provide good support and compensation to nurses. That is why the Visiting Nurse Associations of America works to educate legislators and regulators. The most effective voices are often those of front-line clinicians.


Nurses can be a powerful voice in shaping policy. We have seen it work for member VNAs who cultivate representatives and eventually become trusted advisors. Individual nurses can make a difference simply by writing a letter or voicing an opinion at a town meeting. Elected officials pay attention to constituents. A nurse expressing an opinion on healthcare policy enjoys exceptional credibility.


The VNAA's Web site,, offers tools such as issue briefings and legislative updates to help nurses contact legislators. Federal employees who run regulatory agencies are obviously not elected and therefore more difficult for individuals to approach. But the VNAA does work with regulators closely. We see a key part of our role as opening these officials' eyes to the impact their decisions have on real nurses and patients.


The VNAA has long fought to make OASIS "a less painful and more meaningful instrument," said Robert Wardwell, VNAA's vice president for regulatory affairs. "We have gotten forms shortened somewhat and are encouraged that more reforms are forthcoming."


As "pay for performance" becomes a guiding principle in federal programs, it is essential that clinicians shape performance measurements. We convinced an expert panel to examine how the Medicare prospective payment system (PPS) could better compensate care for patients with various combinations of primary and secondary diagnoses. Nurses from several member VNAs were on that panel, giving regulators a realistic view of the challenges posed by different clinical scenarios.


Not-for-profit VNAs are vulnerable to changes in federal payment policies. For example, the current Medicare PPS system often overcompensates agencies for cases involving high therapy use, at the expense of cases in which skilled nursing interventions are needed to address chronic medical conditions. Some competitors may choose to only accept mostly patients whose care is predictably well compensated. This leaves VNAs and other "mission-driven" agencies to serve the kinds of patients whom others reject, essentially subsidizing their care. With the first major revision to Medicare's PPS on the horizon, the VNAA sees a golden opportunity to end this inequity. The more that individual agencies and nurses become involved, the greater the chance that we will succeed. As the federal budget tightens and the line between payment rules and clinical practice issues becomes blurred by pay for performance, nursing intervention in national policy making is needed as never before.