As part of the Affordable Care Act (“Obamacare”), Medicare payments to hospitals are based on several accountability factors including measurable quality outcomes and a more subjective “patient satisfaction” rating.
No one would argue against satisfying patients, but a recent article in The Atlantic made the case that subjectivity is dangerous, and leads “hospitals to steer focus away from patient health, messing with the highest stakes possible: people’s lives.”
The article was adapted from a book, “The Nurses: A Year of Secrets, Drama, and Miracles With the Heroes of the Hospital,” by Alexandra Robbins. It’s concerned that hospitals are interpreting a government mandate to improve care as the need to provide services akin to four-star hotels. But a nurse is not a concierge.
Nearly one-third of Medicare reimbursements are based on patient satisfaction survey scores. According to the Centers for Medicare and Medicaid Services (CMS), “Delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.”
“They probably had no idea,” said The Atlantic, “that their methods could end up indirectly harming patients.”
Medicare withholds a percentage of its reimbursements from hospitals that don’t measure up. Only those with high patient-satisfaction scores as well as satisfactory care standards are fully reimbursed, and top performers receive bonus funds.
The patient satisfaction survey (the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS) consists of 32 questions, most of which, Robbins said, concern nursing care. One example: “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”
But that question is misleading, she believes, because it doesn’t address whether the patient’s need was urgent, or even medically necessary. Anyone familiar with Yelp knows that consumers are just as likely to gripe about things they find personally annoying as well as significant issues about the delivery of a product or service.
And this is a metric we should accept as a measure of decent medical care?
Hospital survey respondents have complained about things like roommates who breathe noisily, and food service that lacked Splenda (an artificial sweetener). “An Oregon critical-care nurse,” the article said, “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).”
One study, according to the article, showed that patients who reported being most satisfied with their doctors actually had higher health-care and prescription costs. They also were more likely to be hospitalized than patients who were not as satisfied. “Worse,” said The Atlantic, “the most satisfied patients were significantly more likely to die in the next four years.”
The researcher who conducted that study suggested that doctors who are reimbursed according to patient satisfaction scores might simply give in to patients who request certain treatment, instead of discussing the risks, benefits and expectations for its outcome. These might be the same kind of doctors who hand out antibiotics to everyone who walks into their office with a cold and isn’t satisfied unless and until the doctor does “something,” even if it’s the practice of bad medicine.
Some doctors are reluctant to raise concerns about their patients’ smoking, substance abuse or mental-health issues. Sometimes delivering bad news or an explanation of a difficult but appropriate treatment leaves a patient dissatisfied … but well-informed and well-prepared.
So evaluating a hospital like you would a resort leaves it vulnerable, as New York Times columnist Theresa Brown observed, “to doing things it can’t, at the expense of what it should.”
In addition to hospitals spending valuable resources on creature comforts like custom-order room-service meals and VIP lounges for patients enrolled in their “loyalty programs,” many are requiring nurses to undergo unnecessary, nonmedical training.
“Some administrators,” said The Atlantic, “are ordering nurses to use particular phrases and to gush effusively to patients about both their hospital and their fellow nurses, and then evaluating them on how well they comply. An entire industry has sprouted, encouraging hospitals to waste precious dollars on expensive consultants …”
A good nurse listens, is spontaneous and doesn’t need or want a script to tell her how to deliver superior care. Patients aren’t “customers,” and a medical professional’s priority isn’t necessarily “customer satisfaction;” it’s patient care.
Although we are strong believers that the patient ultimately is the person who makes medical decisions for himself or herself, and that medical providers are obliged to engage in constant, effective communication to enable him or her to make those calls, that’s not the same thing as treating patients like customers.
As The Atlantic said, “Comfort is not always the same thing as health care.”
As health systems increasingly use patient satisfaction scores to help determine what nurses and doctors are paid, the possibility increases that providers with fabulous patient satisfaction scores also have a lot of patients with poor outcomes that might have been avoided.
Robbins analyzed Medicare’s publicly available provider data for thousands of hospitals. She found that 2 in 3 of those that performed worse than the national average in three or more categories measuring patient outcome (that is, a higher number of patients than average will die, be unexpectedly readmitted to the hospital or suffer serious complications) scored higher than the national average on the key HCAHPS question, reporting that they would definitely recommend the hospital.
“Patient surveys,” she concluded, “won’t drastically and directly improve health care.
“But research has shown that hiring more nurses, and treating them well, can accomplish just that. It turns out that nurses are the key to patient satisfaction after all – but not in the way that hospitals have interpreted.”
She referred to research linking sufficient staffing of registered nurses to fewer patient deaths, improved quality of health, fewer readmissions to the hospital and shorter hospital stays.
Making patients happy is a noble goal. Making them well, or as well as they can be, is what should count the most.
For help in assessing choosing a hospital, see Patrick’s newsletters “The Dicey Relation Between Hospital Ratings and Superior Patient Care” and “Finding the Right Hospital for You.” And see our backgrounder on hospital errors.