Keep­ing up pa­tient-sat­is­fac­tion scores may be hav­ing an un­in­tended price

Stud­ies show fo­cus on keep­ing pa­tients happy can have un­in­tended costs

Modern Healthcare - - NEWS - Rich Daly

Agroup 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.

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 sat­is­fac- tion 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

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

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