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Disconnect between level of patient satisfaction and quality of care.
Recent studies show a disconnect between the level of patient satisfaction and the quality of patient care.

A satisfactory measure?

Studies show focus on keeping patients happy can have unintended costs

By Rich Daly
Posted: January 5, 2013 - 12:01 am ET

A group of physicians in the UCLA Health System faced a quandary last year. They had decided that a patient was ready for discharge to a rehabilitation facility, but the patient was refusing to leave.

In a push-and-pull seen frequently in hospitals across the nation, the California physicians acceded to the patient's request to delay the clinically appropriate discharge because of their desire to keep the patient happy.

“Sometimes we are inclined to give the patient what they are asking for because we want them to have a positive experience, but we've learned that even if they are asking for something, it is for their own benefit to set boundaries,” says Tony Padilla, director of patient affairs for the Los Angeles system.

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Padilla says such “overshooting”—where their clinicians allow patients to dictate some unneeded care that does not improve their health, but increases spending because of a disproportionate focus on patient satisfaction—is less common than it was several years ago when the health system began a large push around patient satisfaction.

But as patient-satisfaction measures have gained their first real teeth in Medicare, new questions are emerging about whether such tools carry unintended consequences.

Patient-satisfaction responses constitute 30% of each hospital's score under the federal value-based purchasing system, which will either increase or decrease a hospital's overall Medicare payments by up to 1% in 2013. The Medicare reimbursement changes come amid new evidence that providers say shows patient-satisfaction efforts may be counterproductive to efforts to improve care quality and patient outcomes or to control spiraling healthcare spending.

Some hospital executives and physicians question whether patient satisfaction—as it is currently measured—is an appropriate yardstick for rewarding or penalizing hospitals. And some recent studies, they say, indicate a disconnect between improved patient satisfaction and quality of care.

The issue came to the fore at last month's meeting of the Medicare Payment Advisory Commission, when Dr. Rita Redberg, a cardiologist and MedPAC member, cited findings from an unreleased MedPAC analysis of 2011 Medicare claims data and cost reports that found similar patient ratings for hospitals with high and low mortality rates and those found to have high and low Medicare costs.

“If I were a patient, I would notice more how quickly I was seen, how good the food was, whether the nurses were responsive,” she says about the MedPAC finding. “And while that's important, it's probably not related to what we're looking at in terms of quality and cost of care.”

Such findings, she says, echo a disconnect between patient satisfaction, quality and cost identified in a March 2012 study published in the Archives of Internal Medicine. That prospective cohort study of nearly 52,000 patients and the care they received concluded that higher patient satisfaction was associated with greater inpatient care use, higher overall healthcare and prescription drug spending and increased mortality.

The research “documents a correlation between satisfaction and healthcare utilization,” says Dr. Joshua Fenton, one of the authors of the study. “That is the part that clinicians notice.”

Fenton credits the link between patient-satisfaction scores and increased healthcare services to clinicians' increasing desire to accede to requested treatments to please public and private payers, which have increasingly linked their reimbursements to patient satisfaction.

Meanwhile, the push for evidence-based, standardized care as a way to improve overall clinical outcomes while lowering costs has included placing patients in care settings deemed appropriate. In the patients' eyes, that might seem counter to their best interests.

“We are emphasizing that care coordination is everyone's job and everyone must find ways to keep patients out of the expensive sites of care such as hospitals but still maintain high levels of quality and patient satisfaction,” John Sheehan, executive vice president and chief operating officer at St. Luke's Hospital, Cedar Rapids, Iowa, said in an e-mailed response to questions. “That said, many patients still perceive these efforts as reducing or withholding care and are not always satisfied with these new approaches.”

But efforts to restrain patients' requests for unnecessary care also include the addition of services. For instance, St. Luke's has added a pilot program to increase care coordination for patients who seek emergency department care repeatedly throughout the year.

Some experts say instances of the focus on patient care leading to overtreatment, overprescribing and overspending stem from providers underemphasizing the importance of reducing patient-care costs and improving population health.

Lynne Rothney-Kozlak, a leading adviser on patient satisfaction to the Premier healthcare alliance, says providers are more likely to avoid such patient-driven overtreatment by balancing improvements in population health, experience of care and per capita cost of healthcare. However, she acknowledges that a comprehensive measurement system that captures the three-part health reform paradigm has not yet been developed.

“There's no right answer, per se; it's really a balancing act, and sometimes it's at the patient level and sometimes it's at the population level,” Rothney-Kozlak says.

Some hospital advocates see an emerging case for changing the basic instrument that the federal government uses to measure patient satisfaction. That tool, the Hospital Consumer Assessment of Healthcare Providers and Systems survey, or HCAHPS, asks discharged patients whether a range of desired actions occurred during their hospitalizations. The CMS required hospitals treating Medicare patients to begin reporting the survey results in 2006, and the spring 2012 reporting period included 2.8 million surveys from 3,851 hospitals.

“HCAHPS has basically remained constant since its inception and it's basically time to see if it needs tweaking,” says Nancy Foster, vice president for quality and patient-safety policy at the American Hospital Association.

She highlights unpublished research from the Cleveland Clinic that found that patients in poorer health tended to give lower scores, which meant the facilities that cared for higher numbers of the sickest patients also had generally lower scores. So a change in the survey's risk adjustment to account for concentrations of seriously ill patients among some providers may be needed, she argues.

A Modern Healthcare review of CMS patient-satisfaction data found that hospitals and provider groups with high marks showed only a modest improvement in at least one patient-outcomes measure—the readmission rate.

Meanwhile, the research conducted and reviewed by the CMS indicates to officials there that patient satisfaction and clinical outcomes generally correlate among the hospitals that report on the agency's measures.

“The vast majority have shown mild positive association; in other words, hospitals, provider groups and other entities that tend to score higher on one tend to score higher on the other by a small amount,” says a CMS official who is knowledgeable about the program.

The CMS declined to make any official available to speak about the program on the record, but an official who agreed to discuss the program anonymously acknowledged that for some providers, patient-satisfaction scores and their other quality measures will not correlate.

The agency found HCAHPS scores have improved since they were linked to hospital reimbursement. But officials there say that some providers are seeing quality and patient-experience indicators moving in opposite directions.

That leaves some researchers skeptical about the validity of the current HCAHPS.

“To go so far as to say by doing these kinds of measures and holding providers accountable for them you will reduce costs and improve quality is widely accepted by many people, but more research has to be done” to demonstrate that, Rothney-Kozlak says.

The CMS official admits there are no specific provisions in HCAHPS that are designed to prevent overtreatment that drives up costs and ultimately can hurt the patient's health. Instead, it is left up to hospitals to determine how best to improve patients' experience, just as they determine how to improve quality of care.

New patient-satisfaction surveys under development at CMS for other types of providers, such as physician groups and ambulatory surgery centers, will include an “important” focus on patient communication with providers, according to the CMS official.

Some researchers and providers cite a similar focus on measuring communication as one of the most cost-effective ways to use patient satisfaction to improve the quality of care delivered. Measurement that drives quality communication could keep clinicians from overlooking important health problems and encourage patients to take an active role in their care, which carries such side benefits as improving medication adherence.

“If we communicate in a more patient-centered way, we are going to have a higher batting average for getting compliance with patients and making them feel like they are partners in their own care,” says Padilla, the UCLA hospital administrator.

Improving the staff's ability to communicate consistently, effectively and empathetically with patients has absorbed the bulk of the estimated $1 million that UCLA Health System has spent annually on improving patient satisfaction, Padilla says, because it can provide a much bigger impact than more costly cosmetic improvements.

Fenton suggests measuring whether physicians undertook specific types of communication to better convey whether critical information was shared, such as asking whether the physician empathized with them.

“When you just ask a patient, 'Did the doctor communicate well to you,' you really miss that finer grain,” he says. “Whatever gets measured the doctors are going to pay attention to.”

Some outside experts are pushing for improvements in HCAHPS and other patient-satisfactions surveys to better capture nuances in the way different providers deliver care.

The HCAHPS survey's communication questions are currently limited to whether any dialogue occurred between patients and providers and not whether the patients' perspective was understood or whether it allowed them to share in decisionmaking regarding their care, says Dr. Seth Glickman, a patient-satisfaction researcher at the University of North Carolina School of Medicine. Glickman is an unpaid board member of a company that has developed its own patient-satisfaction measurement and interpretation tool.

“We believe that when designed and administered appropriately, patient-experience surveys provide robust measures of quality, and our efforts to assess patient experiences should be redoubled,” Glickman and his colleagues wrote in a Dec. 26 perspective in the New England Journal of Medicine.

CMS patient-satisfaction surveys could better meet that standard, Glickman says, if they provided a better barometer of patient-provider communications.

“That's an area of work moving forward to improve that measure,” he says.

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