“I'm just trying to keep the customers satisfied.”
My clinic is restructuring its physician compensation model, which has led to much consternation among my colleagues. Consequently, our watercooler conversations have become quite interesting. Some are concerned that our pay may decrease, while others argue that the quality measures that are being put in place cannot possibly reflect our “performance” as physicians. Creating a realistic compensation system based on “quality” as well as productivity has plagued medical practice for years. However, the process has been accelerated as our government seeks wider control over the healthcare payment system in an effort to contain costs by rewarding those practicing “cost-effective medicine.”
I was recently informed by a colleague who insisted that “patient satisfaction,” often considered a “safe” metric for assessing physician performance, should not be included in our mix of quality measures. After doing a bit of googling, I discovered he was absolutely correct. In this article, let’s review the importance of patient satisfaction in the big picture of patient care.
It's very complicated!
Physicians are not only providers of healthcare, we are patients as well. As such, we are exposed to 2 sides of our onerous healthcare system. As providers we know what we need to do to expedite diagnosis and treatment for our patients. Because we are patients, we are concerned about the cost of care. Many patients have large insurance deductibles, thanks to the Affordable Care Act, and are very sensitive to the exorbitant price of healthcare. (I recently had a father cry when I suggested ordering a magnetic resonance imaging test.)
To keep costs down, we prescribe the least-expensive medication when options are available, and perform only tests that are necessary to expedite a diagnosis. We believe in presenting options and working with patients to provide the best outcome. In other words, we treat the patient as we would like to be treated ourselves (aka, the Golden Rule of Pediatric Practice). By providing care in this manner, physicians are “satisfied” that they have done their best to care for patients. However, not all patients are “satisfied” with the care we provide.
Parents can be difficult and demanding. Some will not vaccinate, despite advice to do so. Some want antibiotics for viral illnesses, and others request seemingly endless referrals to specialists. Unless we provide what these patients want, they will never be truly pleased with the care provided. There are also patients who left the office following a well visit in good spirits, but who may be disappointed after receiving their bill. And of course, there are patients who want to lose weight but are unwilling to diet and exercise, and some patients are displeased when we try to convince them to stop smoking or remind them of the importance of taking their prescribed medication. The bottom line is that there are patients who have unreasonable expectations and will never be happy.
For decades, hospitals and healthcare systems have used patient satisfaction surveys to help improve the patient experience. The most popular of these is the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, originated by the Agency for Healthcare Research and Quality, a branch of the US Department of Health and Human Services (HHS). There are different CAHPS surveys for assessing hospitals, health plans, medical practices, home healthcare, hospice care, hemodialysis, surgical care, dental plans, Indian healthcare, and nursing home care. These surveys are administered and interpreted by organizations such as Press Ganey that use data analytics to make recommendations to institutions sponsoring the survey.
Survey scores are held in high esteem by health system administrators because most feel these drive patients toward facilities with the best scores. As a consequence, satisfaction is a quality measure used to reward participating healthcare systems monetarily. In turn, these organizations reward their physicians (or penalize them) based on satisfaction benchmarks. Physicians who succumb to the temptation to appease their employer have learned methods to improve satisfaction scores. To keep our customers satisfied, physicians overprescribe antibiotics and pain medications, order unnecessary tests, admit patients when not indicated, and overrefer. As a consequence, physicians’ compensation improves, but the quality of care may suffer. So survey results should be interpreted with caution. Happy patients may not be getting the best quality care, with their “satisfaction” a product of a healthcare system motivated by greed rather than by providing quality medicine.
Just a few years ago, a landmark study was published in the Archives of Internal Medicine that examined the impact of patient satisfaction on healthcare utilization, money spent on healthcare, and mortality.1 The results were enlightening to say the least. More than 50,000 adult patients were surveyed from 2000 to 2007. The researchers used the Medical Expenditure Panel Survey (MEPS) data to assess the relationship between patient satisfaction and healthcare utilization, expenditures, and mortality in a nationally representative sample. Patients were asked to respond to the Consumer Assessment of Health Plans Survey that measured patients’ responses to the following:
Did your physician:
· Listen carefully?
· Explain things in a way that was easy to understand?
· Show respect for what you had to say?
· Spend enough time with you?
Patient were also asked to rate the healthcare received from physicians on a scale of 0 to 10 (from worst to best care).
What was discovered was that more satisfied customers were less likely to utilize emergency department (ED) services, but were more likely to have greater inpatient admissions and have higher overall healthcare costs and mortality. The researchers surmised that patients who were more satisfied with their physicians were more likely to utilize their medical home versus seeking care via the ED. However, the surprising correlation between patient satisfaction and higher admissions and healthcare costs led the researchers to speculate that patients had certain expectations from their providers regarding services such as testing, prescribing, referrals, and so on. Physicians who acquiesced to their patients’ requests and provided discretionary services caused the patients to be satisfied, but by doing so they drove up healthcare costs. Higher mortality may be a consequence of overutilization and the subsequent association with “adverse” events (ie, hospital-acquired infections, medication reactions, and more).
A follow-up “tongue-in-cheek” article published in the Southwest Journal of Pulmonary and Critical Care the same year was hilarious. The authors concluded that in order to reduce healthcare costs, healthcare institutions and physicians should ignore their training and make every effort to increase patients’ dissatisfaction through a variety of creative means.2 These included requests for cash payment for services at the time provided; blood draws and intravenous starts by the least-experienced trainees; providing noisy environments that are either too warm or too cold, and so on. Outcome measures would assess the degree of patient discomfort, and hospital administrators and providers would be compensated based on the level of dissatisfaction achieved.
Satisfaction aside, in everyday practice physicians should make every effort to engage the patient. It takes little effort to smile, encourage your staff to be pleasant and caring, and create an office environment that is supportive of parents’ and patients’ needs. By doing so you are more likely to persuade parents to comply with your recommendations. By providing options you also enable parents to make decisions based on good information and advice, recognizing that they have every right to disagree with you. In some situations, when parents’ demands or decisions may jeopardize the care of the child or place providers in awkward situations, it is appropriate to discharge a patient from your practice or involve protective services.
Time for a change
What is long overdue in any “pay-for-performance” incentive program is the recognition that there may a disconnect between physicians providing quality care and patients following our recommendations. Providers should be given credit for ordering the appropriate test such as regular hemoglobin A1C measurements in diabetic patients, ordering immunizations at well-child visits, and ordering lead tests for children at risk, for example, regardless of whether the patients follow our recommendations. Patients in turn should be made responsible for following our instructions. If we reward good behavior (perhaps by lowering insurance co-pays or deductibles) and penalizing bad behavior (increasing co-pays or deductibles), we motivate patients to make better choices.
Please feel free to contact me with your own “watercooler wisdom” regarding patient satisfaction and related issues. Only by sharing our concerns and recommendations for change can we hope to improve our healthcare system.
1. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5):405-411.
2. Robbins RA, Raschke RA. A new paradigm to improve patient outcomes:â¨a tongue-in-cheek look at the cost of patient satisfaction. Southwest J Pulm Crit Care. 2012;5:33-35.
Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.