As people become more aware of the waste associated with overdiagnosis and overtreatment and as the government strives to make the delivery of high quality health care more efficient and responsive, measures to connect patient satisfaction with provider payment are becoming popular. (See our blog about doctor rating services.)
But one practitioner, writing on KevinMd.Com, has written a thoughtful essay inviting people to reconsider the equation of Satisfaction=Higher pay. Such a model, he suggests, actually might punish the best health-care providers and work against better patient outcomes.
“I hope my patients are satisfied,” Dr. John Mandrola, a cardiologist, writes. “Improving the lives of people is why doctors do what they do. How much we help our patients is the metric. It’s the peg we hang our self-esteem on.”
“So yes, of course, patient satisfaction is really important.”
But, he says, “on a list of well-meaning but really dumb reform ideas, linking compensation of hospitals (or doctors) to patient satisfaction scores ranks near the top. Let me tell you why I think this way. It involves an important baddie-overtreatment.”
“Medical care,” Mandrola writes, “is not the same as customer service. For instance, I believe strongly in the importance of explaining and then implementing TLC-therapeutic lifestyle changes. … Asking or expecting patients to take care of themselves risks converting them quickly to the ranks of dissatisfied. A much easier road for the doctor is to avoid the elephant in the room-and simply write the prescription, order the MRI or refer the patient on to another specialist. This behavior will only worsen if we dis-incentivize doctors to speak the truth. We already have too much care.”
The problem becomes acute when there are two treatment approaches-one involving a well-reimbursed procedure and the other involving a discussion between doctor and patient about lifestyle changes (or other conservative measures) that, if the patient commits to them, might avoid ever needing the more invasive procedure. As Mandrola says, the problem with the conservative approach is the risk of a poor satisfaction score by the patient. “Not doing in our system is far harder than doing,” he says.
“Bigger care, more care, riskier care–these are the reasons why I oppose using satisfaction scores to pay hospitals and doctors.”
One of his patients went to the ER. The problem, Mandrola recounts, was the patient’s inability to follow his earlier advice, as a first-line defense against his heart issues, not to use caffeine and nicotine. Mandrola had also discussed with the patient the importance of adhering to a medically sound regimen of an inexpensive generic medicine. At the ER, Mandrola reminded the patient that “his health depended on him-not me.”
Mandrola’s ER visit confirmed that his patient’s experience was common: The ER was overflowing with patients who had strayed, in Mandrola’s words, “far from ‘the program.'” But the ER staff still had to address their problems as emergencies, possibly serious ones. As one ER doc told Mandrola, ” …[N]ow, with patient satisfaction scores, we have to be extremely careful not to make patients mad.”
Readers of this blog know that while we never defend practitioners who are lazy, uncommunicative or negligent, we also make clear that patients have a huge responsibility in securing their own best care. Being satisfied with your health care is partly up to you.
The use of opioid drugs is another area ripe for a misguided application of Satisfaction=MoreBucks. Sometimes patients aren’t happy with the amount or type of pain medicines they’re prescribed. Sometimes that’s the doctor’s oversight or error, and some patients are deprived of pain meds they need. But sometimes, it’s the patient making an unreasonable demand, one that has contributed to the overuse and abuse of opioids in this country. (See our blog, “FDA to hold hearings on misuse of powerful pain pills.”)
If you don’t give patients the medicine they want, they might not be satisfied with your care, even when it’s appropriate. Satisfying them can be dangerous.
Mandrola ends his essay “with this warning-from the real world of health care–to policy makers:
“What you incent with dollars will happen.”