The Atlantic recently released an article “The Problem With Satisfied Patients” written by Alexandra Robbins covering the idea that patient satisfaction should be used as a indicator of health care quality. In the era of increasing focus on “patient centered care”, the Centers for Medicare and Medicaid Services (CMS) decided rather reasonably that the “delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.” Like many of the government’s ideas with regard to health care, the intent was good but the consequences potentially dire.
In order to enforce the idea, CMS decided that a proportion of hospitals’ Medicare reimbursement would be based on patient satisfaction survey scores. This was codified into law with the Affordable Care Act, which implemented a policy withholding 1% of total Medicare reimbursements to the tune of roughly $850 million. Hospitals with high satisfaction scores would earn the money back, the top performers would received a bonus, and poor performers would lose out on a significant portion of revenue.
It really does make sense – patients receiving high quality care must be satisfied with the care they are receiving. Right? Well… not exactly. Listen, no one doubts the importance of satisfaction surveys, but if you’ve ever browsed through Yelp or TripAdvisor – you’ll notice a wide variety of what people consider to be “quality” when it comes to commercial services like restaurants or hotel stays. The problem is that we aren’t talking about the amount of cheese on your pizza or what the thread count of hotel linens but rather your health and safety. No one is arguing that healthcare doesn’t need to be drastically improved, but you can imagine the great variety of subjective scores hospitals receive – and the resulting financial implications. The problem ultimately is that the scores are leading hospitals to shift the focus from a patient’s health to patient satisfaction, and that patient satisfaction surveys may actually be negatively affecting patient care and therefore people’s lives.
The majority of the patient satisfaction survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), addresses care provided by nurses or nursing ancillary staff. As Robbins points out in The Atlantic, one of the questions on the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” But the question doesn’t specify why help was needed and if that help was medically necessary. Certainly, a patient having chest pain would require help right away, while one requiring an additional pillow may be able to wait a few minutes. Alexandra Robbins notes,
Patients have complained on the survey, which in previous incarnations included comments sections, about everything from ‘My roommate was dying all night and his breathing was very noisy’ to ‘The hospital doesn’t have Splenda.’ […] An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery).
Ok, so maybe the survey became a forum for people to complain, much like lacking Splenda may negatively affect the rating at a restaurant or Starbucks. But satisfied patients may not be suffering only from unrealistic expectations for their care, they may be suffering from overuse of the medical system. Studies have noted that patients who report being more satisfied with their physician have higher healthcare and prescription costs, are more likely to be hospitalized, and are significantly more likely to die within the next four years. Putting too much focus on what patients want may mean they get more of what they don’t need and not enough of what they do. But when reimbursement is closely tied to patient happiness, it begs the question… does patient-centeredness really mean that clinicians should give patients what they want even if they don’t need it? And at what other cost? Evaluating care in terms of its ability to make patients happy may force systems to do things they cant at the expense of what they should.
An even greater peril in basing quality on care on patient satisfaction is that patient’s don’t actually know what constitutes quality care. That’s not meant to be insulting or denigrating to the public at large. The problem stems from a few reasons – one is that government, hospitals, and providers already struggle with defining “quality of care” and then turning those definitions into quantities that can be measured and acted on. The other is due to the natural imbalance of information between patient and provider – patients don’t know what they need. Obviously, a quality physician/nurse/etc should provide that information, thereby creating an informed, prepared patient – but sometimes that information may not be received so well. Sometimes hearing bad news is not going to result in a satisfied patient but at least they are well-informed.
Perhaps the biggest downside of patient satisfaction surveys is that they turn patients into customers. Don’t get me wrong, on some level this is a good idea, especially when the discussion revolves around the cost of care compared to the quality of care; in fact, turning patients into consumers is one of the avenues to reducing the overall costs of care. That of course requires greater transparency in medicine, but the idea of focusing on “patient experience” has, as Robbins points out “mischaracterized patients as customers and nurses as automatons.” By treating patients like customers, hospitals are inadvertently making patients feel like “the customer is always right.” Due to the information imbalance in medicine, the patient actually cannot always be right. Hospitals have spent thousands of dollars on hiring “customer-service representatives” in order to ensure the comfort of their patients, yet the unfortunate truth is that medicine isn’t always comfortable; in fact it can often be painful both mentally and physically, and sometimes necessarily so.
The ultimate tragedy is that some hospitals receive high patient-satisfaction ratings and unfortunately offer extremely poor care. In her article, Robbins researched the hospitals that perform worse than the national average on three or more patient outcome measures – things like being readmitted to the hospital, suffering serious complications during an inpatient stay or mortality rate. Nearly two thirds of those poorly performing hospitals scored higher than the national average on the key HCAHPS question; their patients reported that “YES, [they] would definitely recommend the hospital.”
While they are undoubtedly an important piece of the puzzle, patient satisfaction surveys alone will not drastically or directly improve healthcare. An over-reliance on them may lead to hospitals focusing on “smiles over substance” and pandering to patients’ desires rather than their needs, perhaps ultimately achieving an unintended opposite goal.