What Is Nursing Care Worth?

What is a nurse worth? The question is a century old. Medicare’s own fee schedule shows how much it still leaves out.

On June 27, the American Nurses Association’s Membership Assembly voted to open full national membership to licensed practical nurses and licensed vocational nurses for the first time. Roughly 651,400 LPNs and LVNs work in American hospitals, nursing homes, clinics, and home care, and after a multiyear effort they now have a seat in the profession’s largest organization.

Nineteen days later, on July 16, the Centers for Medicare and Medicaid Services published its proposed physician fee schedule for 2027. Attached to it, as always, is the file that says what clinical work costs.

There is no line in it for a licensed practical nurse.

Not a low rate. Not an undervalued rate. No category at all.

That file prices the clinical staff time inside every office visit and outpatient procedure Medicare pays for. If you work on an inpatient unit it does not pay for your shift, and I will get to why it still describes your problem exactly.

The file is public and anyone can open it. It prices clinical labor by staff type, minute by minute. It distinguishes fifty different staff types. It has a line for a medical photographer. It has a line for a child life specialist, a line for a lactation consultant, a line for an orthoptist, several of which appear in only one or two billing codes in the entire schedule.

For nursing it uses one blended category: RN/LPN/MTA, priced at 54 cents a minute. That single line covers 5,512 of the 7,203 codes that carry any clinical labor at all, which is 76.5 percent of them. A registered nurse, a licensed practical nurse, and an unlicensed medical or technical assistant enter the payment system as one interchangeable input at one price.

The system knows they are not interchangeable. The same file contains a standalone registered nurse line at 76 cents a minute and a standalone medical and technical assistant line at 36 cents. When it prices those two roles separately it prices the nurse at more than twice the assistant. For three-quarters of the codes it does not price them separately.

A blended rate is a reasonable way to price a service that any of several staff types might perform. It is not a way to see which of them did it, or how many of them, or in what combination. And the licensed practical nurse, who never appears alone anywhere in the file, is never priced separately at all.

Here is where I want to be careful, because the obvious reading of that finding is the wrong one.

Nurses have spent two decades building the case for registered nurse staffing. Ratio advocacy is not the problem.

The problem is that it answers a smaller question than the payment system is asking.

“What is a nurse worth?” invites a salary answer, and then a fight about numbers on a unit. It is the argument we are already having and have been having for years. “What is nursing care worth?” is a different question, because it changes the unit from a person to a service. And once the unit is a service, you have to say what actually goes into delivering it.

What goes into it is a team. On any unit, nursing assistants and patient care technicians deliver a substantial share of the direct care a patient receives. Licensed practical nurses hold a license, practice within a defined scope, and carry continuing education requirements to keep it. The composition varies by setting. In every setting it is a team.

The licensed practical nurse is the sharpest illustration of what the narrow frame costs, because the line it drew turns out not to be about licensure at all. LPNs are licensed. They deliver direct care. And while the conversation stayed on registered nurses, the federal fee schedule ended up with no category for LPNs, and as far as I can tell nobody noticed, because nobody was looking.

There is a second thing missing from that file, and it is the one I have spent years on.

Delivering care takes two distinct resources. The first is the direct, hands-on work at the point of care. The second is the staffing required to cover the hours those same people are necessarily away from it: orientation when they are hired, competency training, continuing education, and coverage for vacation, illness, and holidays. Finance conventionally files that second category under indirect and nonproductive time and treats it as overhead to be minimized. In workforce terms it is patient care and patient care support, and the support is not overhead. It is what makes the direct care sustainably deliverable.

The most common staffing formula taught in nursing finance education has understated that second resource for more than sixty years. Take a unit that needs 100.00 positions: 80.00 patient care and 20.00 patient care support, two shares of one workforce that add up to the whole staff. The most common nursing budget methodology does not start from the total. It starts from the 80.00 direct-care positions and applies the 20 percent support figure to those, which adds 16.00 positions for patient care support and budgets a total of 96.00. But 20 percent of the direct-care portion is not 20 percent of the total. The unit needs 20.00 support positions, not 16.00. It is short 4.00 positions for every 100.00 required, before the fiscal year opens. The 4.00 lost positions represent the patient care support resources needed by the 16.00 calculated positions.

If you have ever worked on a unit that was called fully staffed on paper and never once felt like it, this is one of the reasons. The budget was approved. It was also built short of what the unit actually needed, and nobody working the floor was in a position to see that, because the calculation happens somewhere we are rarely ever shown.

That is arithmetic, not judgment, and it is checkable on any real unit budget.

Now look at the fee schedule with that in mind. Its input file lists sixty-eight distinct activities that clinical staff perform: preparing the room, obtaining vital signs, assisting the practitioner, monitoring the patient afterward, cleaning instruments, coordinating what happens next. Every one of them is work done during the visit or the procedure itself. Three of them mention education, and all three mean educating the patient.

There is no activity for orientation. None for competency training, none for continuing education.

Part of the second resource is carried somewhere else. The per-minute rates are wage data adjusted upward by a fringe benefits multiplier, so paid leave is priced into a minute of clinical labor even though no activity names it. Orientation, competency training, and continuing education are not leave. They are worked, paid hours that produce no billable service, and they attach to no minute the method counts.

That part of the support resource is not undervalued in the fee schedule. It is absent from it.

The same set of files prices medical equipment. An anesthesia machine has a purchase price, a useful life in years, a utilization rate, and an assumed number of minutes it is available per year. All of that is carried into the valuation of every service that uses it, because keeping a machine running costs something and the method accounts for it.

Clinical staff enter only as minutes consumed during the service.

Equipment and labor are accounted for differently and nobody should expect identical treatment. The narrow point is the one that matters: the methodology already contains the idea that an input has to be sustained in order to be available. It applies that idea to one class of input and not the other.

The physician fee schedule pays for care delivered in offices, clinics, and outpatient settings. If you work on an inpatient unit, none of those codes pay for your shift, and it is fair to ask what any of this has to do with you.

The answer is that inpatient nursing has the same problem, and it is a century older.

Hospital nursing is not billed as its own service. It sits inside the room-and-board charge, alongside the bed and the meals. That arrangement is roughly a century old. As late as the 1920s, most nurses were private duty and billed patients directly or through nurse-owned registries, and as hospital care industrialized and insurance emerged, nursing was moved into the hospital chart of accounts under hotel services, next to housekeeping and linens. It has largely stayed there. A hundred years on, as John Welton puts it, nurses “remain the only licensed provider unable to bill directly for their services.”

It was not for lack of trying. When the DRG system was designed at Yale in the 1970s, assigning nursing costs by type of illness was a central element of it. New Jersey’s prospective payment experiment tested several ways of costing nursing services. Neither survived into what Medicare adopted. One state built the adjustment anyway: New York allocated nursing cost to each DRG in its Medicaid payment for two decades, using weights set by a panel of nurses convened by the state nurses association under the aegis of the state health department.

So there are two payment systems, built at different times by different people. In one, nursing care is folded into the room rate. In the other, it is a cost input inside somebody else’s billed service. Neither of them prices nursing care as a thing with a value of its own, which is exactly why neither of them can tell you what it is worth.

Medicare is not indifferent to what happens when nursing care is thin. Under the Deficit Reduction Act of 2005, CMS maintains a list of fourteen hospital-acquired conditions that are high cost or high volume, that would otherwise raise what a case pays when they appear as a secondary diagnosis, and that in the agency’s own words “could reasonably have been prevented through the application of evidence-based guidelines.”

Four of those fourteen are outcomes long classified as nurse-sensitive: stage III and IV pressure ulcers, falls and trauma, catheter-associated urinary tract infections, and vascular catheter-associated infections. Since 2008, a hospital gets no additional payment when one of them develops on its watch.

So the resource those outcomes are sensitive to is not counted when services are valued, and the outcomes themselves carry a payment consequence when they occur. Both of those are Medicare policy, written in different files, by different people, at different times.

John Welton named that dilemma in 2008, when the first of these conditions took effect. Most of them, he wrote, are “clearly, if not primarily, nursing related,” and the payment system they sit inside does not account for nursing care separately anywhere. Eighteen years on, the fee schedule shows the same shape in a different file.

All of this points at one principle. Naming it is what turns it into something CMS could adopt.

Any method that assigns a value to clinical work has to account for the full resource required to deliver that work sustainably. That resource has two dimensions.

The first is who delivers the care: the whole nursing care team, not a single licensed role.

The second is what has to be funded so they can. Direct patient care time and patient care support time (orientation, education, paid time off, and leave), both of them, added together as one total. Not the direct hours alone with the support treated as overhead somewhere else on the ledger, and not the support estimated as a percentage bolted onto the direct hours after the fact. They are two shares of one workforce, and a valuation carrying only one of them is describing a workforce that does not exist.

Call it the full resource basis of valuation. It reduces to a single question you can put to any payment method, the one in use now or any of the alternatives:

Does it price the visible task, or the full resource the task requires?

Put that question to the current process and it fails on both dimensions at once. Put it to the alternatives being floated, including paying for services on a different code set, and the answer does not improve on its own, because the omission is in the resource basis rather than in the codes. A more precise estimate of task minutes is still a precise estimate of the wrong thing.

One thing this is not. It is not an argument that nurses should bill Medicare directly. Direct billing authority would take an act of Congress, it is a separate fight, and I am not making it here. The full resource principle applies wherever a price is already being set, by whoever is already setting it. It asks nothing about who holds the billing privilege and everything about what the number is supposed to represent.

The proposed rule carries two open requests for information. One asks whether better alternatives exist to the current process for valuing physician services. The other asks how technology and AI have “impacted the resource costs associated with primary care practice, in terms of the time and intensity of services delivered,” and, where those tools free up capacity, “what are clinicians and other health professionals doing with the additional time/bandwidth created.”

Both turn on the same question: what does a valuation method count as the resource required to deliver a service?

Here is the part that matters more than the deadline. When a federal agency proposes a rule, it is required to open that proposal to public comment, and the obligation that follows is not a courtesy. In the Supreme Court’s words, “an agency must consider and respond to significant comments received during the period for public comment” (Perez v. Mortgage Bankers Association, 2015). Comments are not tallied like votes. They are read, and the significant ones have to be answered on the record.

You can watch this happen. Open the finished version of last year’s fee schedule and much of it is CMS answering the public one item at a time, in a format that reads “Comment:” and then “Response:”, hundreds of times over. Sometimes the answer is no. In one exchange, CMS declined a change that commenters had asked for on the grounds that making it without proposing it first would deny everyone else the chance to weigh in.

And this channel does not run through anyone. You do not need your manager’s approval, your employer’s sign-off, an organization behind you, a title, a credential, or a fee. There is no committee deciding whether your comment is worth passing along. You file it and it is in.

Almost everything else in our working lives goes through somebody. The chain of command. The council that meets and reports up. The engagement survey that gets summarized before anyone above reads a word of it. This one does not.

Comment on CMS-1848-P closes September 14. The docket, which is just the public file where comments on a rule are collected, is CMS-2026-2377 on regulations.gov.

What a comment from you would need to contain is smaller than you think. Not data. Not citations. Not a legal argument. CMS asked what it costs in time and intensity to deliver care. The thing it cannot get from anyone else is what you have actually seen:

• How long your orientation really was, and whether it got shortened.

• What happens on your unit when two people call out, and what that looks like by hour three.

• Whether your assistive staffing changed, and what happened after it did.

• Whether anyone has ever shown you the budget your unit runs on.

• What you were told about staffing versus what the assignment actually was.

A few honest paragraphs about one unit is a real comment. It takes about as long as writing a careful email, and it is worth more to the agency than a hundred people agreeing with me in identical words.

Three things to know before you write. Comments are public record and stay searchable. If putting your name on that is what stops you, the form gives you an anonymous option, and the only thing you give up is the confirmation email. You are filing for yourself either way, not for where you work, and you can describe exactly what you have seen without naming the place you saw it. Most useful comments do precisely that.

What one comment will not do is decide the outcome by itself. What it does do is put what you know into the record permanently, where anyone arguing this later can cite it, including you. Right now that record holds almost nothing from the people who actually deliver the care, and that is not because we were excluded. It is because almost none of us knew we could walk in. Out of approximately 2,654 comments at the time of writing this article, there were only 268 comments referencing “nurse” or “nursing”.

I filed one on this question. It is published in full in a companion piece, along with the whole walkthrough and one instruction that matters more than the rest: do not copy mine. CMS says in this rule that it “continues to encourage individuals not to submit duplicative comments.” It will still post identical ones. Your unit is the part nobody else can file.

Most nurses do not know that door exists. It does, it is open until September 14, and the question behind it is not what a nurse is worth. It is what nursing care is worth, and right now the file that answers it cannot see many of the people delivering it.

View the companion article for tips on submitting your own comment to CMS.

1. American Nurses Association. Membership Assembly votes to approve landmark bylaws change to include LPNs/LVNs. News release, June 27, 2026. nursingworld.org

2. Centers for Medicare & Medicaid Services. CY 2027 Medicare Physician Fee Schedule proposed rule (CMS-1848-P). 91 Fed. Reg. 43842, July 16, 2026.

3. Centers for Medicare & Medicaid Services. Direct practice expense input public use files for CMS-1848-P. cms.gov The clinical labor file, the labor task detail file, and the equipment file are the source of every staff type, per-minute rate, activity code, and equipment figure above.

4. Ward WJ Jr. Health Care Budgeting and Financial Management, 2nd ed. Praeger, 2016, p. 130.

5. Gunn ML. A Method for Developing a Master Staffing Plan for the Nursing Service Department. Catholic Hospital Association, 1960.

6. Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions, under section 5001(c) of the Deficit Reduction Act of 2005. cms.gov

7. Welton JM. Implications of Medicare reimbursement changes related to inpatient nursing care quality. JONA: The Journal of Nursing Administration 2008;38(7/8):325-330.

8. Welton JM. Billing for nursing care: a 100-year-old problem. JONA: The Journal of Nursing Administration 2024;54(9):447-448.

9. Knauf RA, Ballard K, Mossman PN, Lichtig LK. Nursing cost by DRG: nursing intensity weights. Policy, Politics, & Nursing Practice 2006;7(4):281-289.

10. Perez v. Mortgage Bankers Association, 2015. law.cornell.edu

11. Centers for Medicare & Medicaid Services. CY 2026 Medicare Physician Fee Schedule final rule (CMS-1832-F). 90 Fed. Reg. 49266, November 5, 2025. federalregister.gov

12. Docket CMS-2026-2377. regulations.gov

I work on nurse staffing, nursing finance, and workforce analytics, as a writer and commercially, so I have a commercial interest in how nursing’s contribution is measured and valued. Every figure above comes from CMS’s own published files, listed in full in the sources.

© 2026 Robert L Wingo - All rights reserved.

Robert Wingo, BSN, RN, NI-BC is the author of the Nurse Staffing Information Structures (NSIS) framework, a mathematical and conceptual approach to understanding and describing the nurse staffing life cycle from reimbursement through outcomes. He is a board-certified informatics nurse, has worked in nurse staffing and scheduling operations, healthcare finance, and data analytics since 1999, and is a Nursing Economics Fellow (FINE Fellowship, Commission for Nurse Reimbursement).