Patient Satisfaction Is No Simple Equation
Patient satisfaction is a buzzword in health care and in Washington. If you Google "patient satisfaction," you will get more than 7.4 million results.
The results range from commentary and scholarly articles to details about the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. Innumerable companies will help you "improve your patient satisfaction scores."
This focus appears to be well deserved. If Americans are going to spend $2.3 trillion on health care (of which 31% represents inpatient care), then they should be satisfied too, right? Maybe not.
In a national study of patient satisfaction, health care utilization, expenditures, and mortality published by investigators from the University of California, Davis, higher patient satisfaction with doctors was associated with higher inpatient utilization, higher cost, and increased mortality, compared with less-satisfied patients (Arch. Intern. Med. 2012;172:405-11). The ultimate conclusion of this observational study is that we really don’t know how patient satisfaction is related to other aspects of high quality care. It has certainly been suggested that patient satisfaction is directly linked to high-value care (that is, quality divided by cost = value), but this current study raises serious questions about that conclusion.
More important to this discussion is the plan to link hospital reimbursement and financial payments to doctors based on patient satisfaction scores as measured by the HCAHPS survey.
In light of the available evidence, is this really a good thing? Probably not. Unfortunately, in an effort to rein in the growth of health care expenditures in this county, our government is experimenting on the health care system. As in the Institute for Healthcare Improvement model (which former Centers for Medicare and Medicaid Services Administrator Don Berwick cofounded), change is seen as inherently good whether you are moving forward or backward. If everything is changing (even in a willy-nilly fashion) a positive breakthrough is more likely to occur. That certainly sounds nice on paper, but these changes can and predictably will have negative adverse consequences that may hurt our patients more than they help them.
I would like to share a personal story that highlights the complexity of patient satisfaction and high-value care. As an employee of the Cleveland Clinic, I had an opportunity last spring to reduce my health insurance premiums if I participated in a program that included routine preventive care, exercise, and adoption of healthy behaviors. As a 43-year-old man, I was physically active and otherwise healthy, and up to that point I had never required a regular doctor. I contacted a colleague to be "my doctor," as I needed a statement from him if I were going to participate in this program. At this point, my satisfaction score was low; I didn’t want to see a doctor at all.
I made an appointment for an executive physical (a nice benefit as a member of the staff health plan) with my new doctor. The executive physical includes a flexible sigmoidoscopy. At the time, I figured if I were going to get the "works," I might as well get a colonoscopy instead. I asked my new doctor if this was alright, even though I knew it wasn’t indicated according to the preventive health guidelines. My doctor (my friend and colleague) said this was fine.
My satisfaction level was going up.
I proceeded to have a colonoscopy last July. Much to my dismay and shock, I learned that I had asymptomatic but advanced colorectal cancer at the age of 43. I am not sure what my patient satisfaction was at that time, but I certainly was not happy.
Approximately 1 week later, I was in preoperative holding at the Cleveland Clinic waiting for my colon resection. One of the nurses asked me where I would like to go after the surgery: the "VIP floor" (known as the Founders Suites) or the colorectal floor. As a physician and a member of the professional staff at my hospital for over 15 years, I knew I would get greater expertise with the colorectal nurses and staff on the colorectal floor, compared with our Founders Suites. I was able to make an informed choice to accept the double room on the colorectal floor (with all the associated smells!), compared with the private and lavishly appointed "VIP" suite. My satisfaction level went down, although I knew I made the right choice. I seriously doubt that a patient without that medical training and perhaps inside knowledge would have made the same choice that I did.
