Thursday, April 23, 2015

Does Patient Satisfaction Matter?

In a provocative article for The Atlantic, Alexandra Robbins posits that we may have a "problem with satisfied patients."  Ah, only in health care...

Ms. Robbins fears that hospitals may be focusing too much on making patients happier, rather than on making them well.  She cites how hospitals are rushing to provide "extra amenities such as valet parking, live music, custom-order room-service meals, and flat-screen televisions," which may help patients have a better experience but which mean resources not going directly to patient care.

She may have a point.

Ms. Robbins' analysis found that hospitals that do poorly on three or more categories of patient outcome measures actually score above average on patient satisfaction.  In her words: "Many hospitals seem to be highly focused on pixie-dusted sleight of hand because they believe they can trick patients into thinking they got better care."


Ms. Robbins cited a 2012 study by Fenton, et. alia, that further quantified the patient satisfaction "problem."   According to their research, patients with the highest satisfaction also have higher odds of inpatient admissions, greater prescription drug expenditures, higher overall expenditures, and higher mortality.

The authors speculated that, in some cases, physicians may be acceding to patient requests for services that are of little or no medical value, thus potentially raising satisfaction but also costs.  Any way you look at it, though, the correlations are not good news for patient satisfaction advocates.

Patient satisfaction is clearly in vogue, as evidenced by CMS unveiling its star ratings on Hospital Compare last week, based on HCAHPS results, and by Medicare's increased focus on value-based payments.  The 2015 HIMSS Leadership Survey found that 87% of respondents listed patient satisfaction as their organization's top priority, higher than even sustaining financial viability (85%).

I was worried that CMS would cave to special interests and publish a Lake Webegon ranking, where all the hospitals ended up above average, but the data appear only moderately skewed upwards.  As reported by Kaiser Health News, out of some 3500 hospitals receiving ratings, fewer than 10% -- 251, to be exact -- received the highest rating of 5 stars.  Forty percent received the average (3 stars), and 34% received 4 stars.  Three percent got only 1 star.

The KHN analysis asserted that many of the 5 star hospitals are small hospitals that focus on "lucrative elective operations such as spine, heart or knee surgeries."  In other words, they may be essentially cherry-picking the patients and patient experiences that end up leading to higher scores.  I suspect Ms. Robbins would agree.

AHA's official response to the CMS ratings was cautionary: "There's a risk to oversimplifying the complexity of quality care or misinterpreting what is important to a particular patient, especially since patients seek care for many different reasons."

OK, fair what does AHA propose instead?

In a post on The Health Care Blog, Ashish Jha, MD, did a deeper dive on the results.  213 of the 5 star hospitals were small hospitals; none were large hospitals.  Teaching status seemed to hurt patient satisfaction, as did being an urban or safety-net hospital.  Interestingly, both for-profit status and higher margins tended to result in higher ratings.

Dr. Jha isn't sure what drives the results: "It may be that sicker, poor patients are less likely to rate their care highly. Or it may be that the hospitals that care for these patients are generally not as focused on patient-centered care. We don’t know."

He is, however, relatively sanguine about the somewhat counter-intuitive results, noting that CMS is using the "gold standard" for patient satisfaction.  He acknowledges that there may be a disconnect between the types of hospitals that we traditionally assumed were high quality and the star ratings, but says: "Whether that is a problem or not depends wholly on how you define what is a high quality hospital."

Another study on patient satisfaction, by Vanguard Communications, looked at patient reviews of physicians, and also found some unexpected results: "Ironically, the analysis indicates that generally as a doctor’s level of education and training increases, patient satisfaction actually decreases."

I didn't see that one coming.

Even more curiously, the Vanguard results found that, on average, non-M.D. providers scored higher than M.D.s, with the highest rating going to naturopaths, a category I have to admit I didn't even know existed (naturopathic doctors, or ND/NMD, are licensed in 17 states).  Audiologists were second, with psychiatrists coming in last (family doctors also scored near the bottom).

Vanguard believes that the ratings reflect more about customer service than clinical quality.  Ron Harmon King, Vanguard's CEO, says:  "Does that mean more highly trained specialists deliver poorer customer service? We can’t say with any certainty, although we found a correlation."

The Physicians Foundation 2014 survey found that 42% of respondents did, indeed, list a customer-service related reason for why they were satisfied with their family physician, way ahead of actual treatment related reasons (26%).  Then again, only 30% of those patients blamed physicians for rising costs of health care, versus the easier targets of insurance companies (75%) and drug companies (74%).  In that they are like their physicians.  Both groups are somewhat myopic on that issue, which doesn't give one much confidence about the satisfaction scores either. 

Ms. Robbins is thus not alone in being skeptical about patient satisfaction scores.  She backed up her skepticism with a quote from nurse Amy Bozeman: "The patient is NOT always right. They just don’t have the knowledge and training."  

I hate to break it to either of them, but even with all our health care professionals' knowledge and training, our health system's record on quality is pretty dismal.

Look, patient satisfaction is not a perfect measure, nor should it ever be the only measure used, but it has to be an important measure.  I can see patients being initially swayed by amenities or even simple courtesy, neither of which have typically been in abundance in our health system.  But we can't afford to forgo the burgeoning effort to focus on improving patient satisfaction.  At some point we have to trust that patients will see through smiles and nicer waiting rooms, and judge quality based on whether they are actually getting better.

And, in fact, research from Johns Hopkins suggests that patients may not fall for "pixie dusted sleight-of-hand" tricks after all.  The study concluded that:
"Patients responded positively to pleasing surroundings and comfort, but were able to discriminate their experiences with the hospital environment from those with physicians and nurses...Hospital administrators should not use outdated facilities as an excuse for suboptimal provider satisfaction scores."  
As Abraham Lincoln famously said: "You can fool all of the people some of the time, and some of the people all the time, but you cannot fool all the people all of the time."

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