Should patient satisfaction factor prominently into healthcare pay-for-performance incentives? That question recently became moot as the Centers for Medicare & Medicaid Services (CMS) began withholding 1% of hospitals’ Medicare reimbursement as part of its Hospital Value-Based Purchasing Program, restoring it to institutions based upon their quality performance. Thirty percent of the program’s financial incentive is based upon how well hospitals score on patient satisfaction, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
Despite those data having been collected and reported for years, their use as a healthcare performance indicator continues to be controversial. To win back reimbursement withholds, hospitals must earn perfect scores: The only winners are the ones for whom patients respond “always satisfied” to such questions as “How often did doctors treat you with courtesy and respect?” or “How often did doctors explain things in a way you could understand?” or “How often did hospital staff tell you what the medicine was for?”
A perfectly happy patient, skeptics say, isn’t necessarily one who has received the best medical care, and several analyses suggest that HCAHPS has unintended biases, making it a flawed accountability tool. Some of the nation’s most prestigious hospitals, for example, receive bad patient reviews despite getting high scores on clinical quality metrics.1
Conversely, many hospitals that receive high patient ratings have low clinical quality marks (e.g. significantly worse mortality rates than the national average for heart attacks, heart failure, or pneumonia).2
Safety-net hospitals perform more poorly than other hospitals on nearly every HCAHPS measure of patient experience, with gaps that are sizable and persistent. These institutions have the most fragile operating margins and are the least able to absorb the additional reimbursement cuts that will result from their low scores.3
Teaching hospitals and other large hospitals also score more poorly, on average, than do small community hospitals.4
Unexplained geographic disparities persist, with hospitals in cities and certain regions, such as the Northeast and California, scoring lower than other regions.1
Quality Requires Clarity
“These are valid criticisms. Just because someone receives the best medical care doesn’t mean they are the happiest—and vice versa,” says Peter Short, MD, senior vice president of medical affairs for Northeast Hospital Corp. in Massachusetts. “Are there biases [in the way patient satisfaction is measured]?
Absolutely. But we’re all being held accountable and we can’t wait for a perfect system.
“Any definition of high-quality medical care must take into consideration how it is perceived by patients,” he adds, particularly when “value” in healthcare means delivering high-quality, patient-friendly care at the lowest cost.
James Merlino, MD, FACS, FASCRS, chief experience officer for Cleveland Clinic, says little peer-reviewed research exists to show that HCAHPS is a robust process of measuring patient satisfaction, but he says CMS is “focusing on the right areas.”
“It’s hard to say that paying attention to the patient experience is not something we should do. And yet, many physicians and hospitals have not done a good job focusing on patient satisfaction,” Dr. Merlino says. “How well we communicate with patients goes to the heart of the patient-provider interaction: It’s crucial that patients are clearly informed what to do while they are in a hospital and after they are discharged. Poor communication can drive confusion, noncompliance, and complications.”
Hospitalists and their teams might begin to think about processes that enhance a patient’s health confidence, which is very strongly associated with many outcomes.
—John Wasson, MD, emeritus professor of community and family medicine at Dartmouth Medical School
Hospitalists will be leaders in driving patient satisfaction, Dr. Merlino says, given their central role in managing patients across the continuum of care. That role gives them great responsibility—and opportunity—to champion practices at their institutions that improve the hospital experience of their patients, many of whom have complicated illnesses requiring a potentially bewildering array of tests and procedures.