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Worrying about patient satisfaction only harms the patient

by Craig Klugman, Ph.D.

Anyone who has been in a hospital in the last 9 years has encountered a patient satisfaction survey. This national survey provides rankings of hospitals based on how satisfied patients are with their experience. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) “is a survey instrument and data collection methodology for measuring patients perceptions for their hospital experience.” For anyone who works in a hospital, the results of this survey can mean raises, firings, and changes of position.

The Centers for Medicaid & Medicare Services and the Agency for Healthcare Research and Quality developed this 27 question survey that has been administered to all hospital patients after discharge since 2006. The Deficit Reduction Act of 2005 requires hospitals to collect this information if they wish to receive their annual payments from CMS. Those with low ratings can lose funding and those who rank lowly on national and local scales are expected to make changes.

The first 20 questions ask discharged patient to choose on a Likert scale about their treatment with courtesy and respect; being listened to; clarity of explanations of treatments, procedures and drugs; help received when desired; cleanliness of facilities; ambient noise levels; pain control; understanding of discharge information. Two questions ask about comparing your hospital stay with previous stays and whether the patient “would recommend this hospital to your friends and family?” Patients are then asked a series of demographic questions. That’s it. There’s nothing about whether they were cured or treated. There was nothing about whether the physician was adequately trained. It’s the same survey that sits on the tables of restaurants and in hotel rooms. You can find the questions in various languages by clicking this link.

The reasons behind this move are simple—it’s an attempt to further commercialize the health care industry. It is not coincidence that “patient satisfaction” sounds similar to “customer satisfaction,” because that’s exactly what it is. A 2013 article in Forbes magazine even states this “patient satisfaction – customer service, really.” The author, Micah Solomon, a business consultant, suggests what hospitals can do to increase their HCAHPS scores. 1. “Patient’s don’t stop being consumers—customers—when they put on a hospital gown.” 2. Focus on how you greet people and how you send them off. 3. Know how to apologize. 4. Have each “employee” (not professional) know his or her place. Notice anything missing? How about nurse-to-patient ration? How about Board certification of physicians? How about rates of infection? No? Apparently what matters is that each employee knows how to greet the patient and what their “place” is in the organization.

Aye, there’s the rub. The reason that customer satisfaction is a bad idea is that it presumes medicine is a business when it is not. It also assumes that a patient has enough knowledge to what is wrong with him or her, what treatment is needed, and where it can be gotten for the best price. A customer is someone who has choice on where to shop, choice in what products to purchase, and can educate him or herself on the products available. In medicine, the product is controlled by a trained and licensed professional because it is highly specialized and complicated. Insurance companies restrict choice of health care providers and hospitals. Hospitals do not even provide information on their pricing unless you read through a 163,000 line spreadsheet produced by Medicare. And even if you can get a price, remember that different insurance plans have different price agreements with different providers, hospitals and physicians often charge separate bills, and there are lots of ancillary fees.

Medicine is a highly specialized service. Doctors have a minimum of 11 years post-secondary education. Most health care professionals pass national exams and hold licenses granted by the states. An understanding of diagnosis, prognosis and treatment also requires continuing education and practice. And yet politicians and MBA administrators would have us believe that the “patient perception of their hospital experience” is actually the best way to measure the delivery of medicine.

Surely then, high patient satisfaction ratings must mean better medicine and lead to better health outcomes? The answer is that there is little correlation. A study published in JAMA Internal Medicine in 2012 showed that high patient satisfaction ratings are correlated with lower emergency department use. When adjusted for all confounding variables, a high rating was correlated with higher chances of a hospital admission, greater cost, greater prescription drug expenditures, and higher mortality. That’s right, the hospitals with the highest customer ratings also are more likely to have their patients die and to cost them a lot of money. This is not a fair representation, but it does show that focusing on customers instead of on medicine leads to worse outcomes and harms the bottom line.

One could argue that these results are because those hospitals with higher ratings take sicker patients with more complicated health issues. The researchers controlled for these explanations. They found that “satisfaction correlates with the extent to which physicians fulfill patients’ requests” even if those requests are medically unnecessary. That is, patients get more tests even if they do not need them, and more procedures and drugs even if they are of doubtful utility. The authors point out that true patient-centered care requires more communication found in longer physician visits, which is antithetical to the business ethos.

One might then ask whether satisfaction is related to better preventive care so that fewer medical services and hospitalizations occur. A 2014 follow up study even found that there was no correlation between patient satisfaction and receiving preventive care.

Medicine and health care are not businesses. They do not operate according to market principles. When business models are applied where they are not appropriate, the result is higher costs, lower levels of service, and poorer quality (think privatization of roads and municipal resources). But in medicine and health care, the outcome is that people are sick and people die. The potential harms and the costs in lives and quality of life are too high to continue down this wrong path. Customer/patient satisfaction is the wrong way to measure how health care is doing because it does not measure health care, it measures patient perception of the quality of their hotel stay.

It’s time for Congress to remove the financial incentives from HCAHPS and it’s time for hospitals to stop putting so much emphasis on them because in the end, such efforts are only harming patients. And isn’t harming patients what we are all supposed to be avoiding?

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