Unsatisfactory marks

Even as hospitals brace for the uncertain impact of linking patient-satisfaction scores to Medicare payments starting in October 2012, some hope for tweaks in the system before that time.

The CMS plans to base 30% of hospitals' scores under the value-based purchasing initiative on patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, or HCAHPS, which measures patient satisfaction. That overall score could affect at least 1% of a hospital's total annual Medicare funding.

But some hospital advocates and researchers have warned that the survey has undergone little peer-reviewed validation and does not account for apparent patient biases.

“We have to be careful about how we hold hospitals responsible,” says Dr. James Merlino, chief experience officer at the Cleveland Clinic, which has conducted research on patient-satisfaction surveys. “We should be holding hospitals responsible for things that they can actually improve.”

The few published analyses of HCAHPS surveys have found their respondents generally disfavor organizations such as large, academic hospitals in northern regions of the country that treat large numbers of patients with either depression or complex and serious illnesses. Those poor patient scores come regardless of the high quality of the clinical care that other measures have found those institutions provide.

Among the practical impacts of such perceived biases is that no hospital in the nation with 500 or more beds has scored in the 90th percentile for such basic measures as physician communication or nurse communication, one Cleveland Clinic study found.

The cumulative impact of the HCAHPS biases, according to hospital advocates, indicates that small community-based hospitals in the Southeast perform best on the surveys, based on their current design. The regional disparities consistently result in hospitals in the South and Midwest ranking higher and those in Northeastern states lower, according to Medicare's Hospital Compare website.

Differing expectations of hospital care in various regions of the country produce patient-satisfaction results that sometimes run counter to reports on the quality of the hospitals' clinical care, according to patient-satisfaction researchers.

However, some hospital officials say ongoing discussions with the CMS and the Agency for Healthcare Research and Quality, which designs the survey, could produce some changes in the methodology of the surveys in an attempt to account for the perceived biases.

Among the changes reportedly under discussion are modifications to the methodology of the survey to add risk adjustments and population adjustments.

Officials at the CMS did not confirm or deny whether discussions of changes to HCAHPS are under way.

Another complicating factor on the impact of the patient-satisfaction surveys are some indications that their biases may be offset by other components of the value-based purchasing program.

Nancy Foster, vice president of quality and patient safety with the American Hospital Association, says that earlier reviews of such data found teaching hospitals that perform poorly on patient satisfaction tend to receive higher scores on process-of-care measures than nonteaching hospitals. She says that is one of the many issues the AHA plans to track as the value-based purchasing program rolls out, which also will include identifying the hospitals that are struggling or exceeding expectations under the program and why that is happening.

“For the ones that are succeeding, our hope is to find that secret sauce and make sure everybody knows how to better serve their patient population,” Foster says.

The unintended biases of hospital patient-satisfaction surveys also could arise in other healthcare settings where the CMS is reportedly planning to add surveys, including physician offices and outpatient hospital care.

Outpatient treatment centers could present some of the greatest accuracy challenges, according to hospital officials, because ambulatory healthcare services differ so widely. A single survey could struggle to capture perceptions of care quality among patients visiting a primary-care clinic and those receiving complex treatments, such as chemotherapy.

“How you create a survey that works for all of those different kinds of clinics and is useful and helpful in understanding what's going right and what's not going as well as you intend and then enable comparisons across settings is a significant challenge,” Foster says.

Another potential complication also emerging from new patient-satisfaction survey analyses is that high marks for perceptions of care may have little connection to high quality clinical outcomes.

One recent analysis of Medicare patient-satisfaction survey data and mortality statistics, conducted and published this month by USA Today, found hospitals given the highest patient ratings also had high death rates.

The findings didn't surprise Merlino of the Cleveland Clinic because patients are not trained to understand the factors that constitute high-quality care.

“They can mistake that for how they are treated in the environment, which is not a good surrogate marker for the medical care that is being delivered to them,” he says.