Hospitals, physicians to face assessments of patient satisfaction
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If television's "House" and Dr. Perry Cox from "Scrubs" have taught us anything, it's that terrific physicians can have lousy bedside manners. And hospitals with bland food and noisy hallways can still provide quality care.
So what are physicians and hospitals to make of the quality-of-care metrics being rolled out by Medicare and some insurers meant to measure somewhat subjective factors, such as a primary care physician's communications skills, a specialist's common courtesy, a nurse's promptness, a hospital's noise environment and the patient's overall "experience?"
"There really is a range of opinions and perspectives on scoring in general. For some physicians and medical groups, they will embrace this," said Dale Shaller, a health policy consultant from Stillwater, Minn. "Others aren't there yet, and have more skepticism about the importance of this, or the technical methodology."
However they feel about it, they had better get used to it.
As payers -- that is, health insurers and state and federal government health programs -- try to wring more value out of their dollars, they are taking a closer look at not just the quality of that care, but also the patient's satisfaction. Soon they will be paying hospitals and physicians accordingly.
In October, the federal Centers for Medicare & Medicaid Services will begin adjusting the way it reimburses hospitals, trying to account for the quality of care through what's being called the "value-based purchasing" program. It's part of Medicare's broader move away from the traditional, fee-for-service reimbursement model, which pays hospitals for every test, surgery or visit, regardless of the quality.
One obvious way to measure care is by the outcomes -- do sick people get better, are readmissions reduced, are hospital-acquired infections avoided?
Another way to measure quality, though, is by "patient experience."
It may be a more subjective class of measures, but it's an important one, born of data showing that adverse events -- such as hospital readmissions -- often can be traced back to those intangible areas. Hospitals, so concerned about their satisfaction rankings, are beginning to hire "chief experience officers," or CXOs, whose job is to make patient experience a priority.
"There are a lot of studies that show that when patients have a better experience, they have better outcomes," said Kent Bottles, a physician, health care executive and instructor at Philadelphia's Thomas Jefferson University.
"The more progressive doctors realize that this is an area that could use improvement," especially when it comes to communications, Dr. Bottles said. If, for example, a hospital isn't effectively communicating what a patient should be doing after he leaves the office -- diet, exercise, medication regimen -- then that lack of communication can undermine the best of in-clinic care.
Still, despite all the medical literature that points to the importance of good communication, "There's always a concern that the way we measure [patient] engagement may not be totally fair."
It may be particularly unfair for hospitals in depressed areas, by one study's accounting. A July study in the Archives of Internal Medicine finds that so-called "safety net hospitals" -- those that tend to serve poorer areas and patients -- also tend to get poorer satisfaction grades from patients, compared to hospitals in areas with more favorable economic conditions.
The authors wrote that safety net hospitals "performed more poorly than other hospitals on nearly every measure of patient experience and that gaps in performance were sizeable and persistent over time ... The greatest differences were in overall hospital rating."
That finding has financial implications for such hospitals, as Medicare starts calculating a percentage of the hospitals' total reimbursement based on quality-of-care scores, called the Hospital Value-Based Purchasing program. That starts in three months. Thirty percent of that quality score will be determined by "patient experience" ratings.
Overall scores, in turn, will affect about 2 percent of a hospital's regular Medicare payments; if they meet standards, they'll get that 2 percent bonus, and if they don't, they'll lose it.
In other words, a hospital that is already handicapped by its location and customer demographics may be further punished by Medicare, pushed "closer to the brink of bankruptcy," according to an editorial in the Archives of Internal Medicine that accompanied the study (archinte.jamanetwork.com/article.aspx?articleid=1217207).
Physicians will see their own Medicare pay models change over the next few years, using a variety of effectiveness measurement tools. And while much of that grading will hinge on patient outcomes and preventive care, some of it will likely be tied to patient experience measures.
The 2010 health care overhaul prompted the creation of a "Physician Compare" website, which went live Jan. 1, 2011. That website will, by 2013, be drawing on clinical data now being collected through the Physician Quality Reporting System.
Eventually, patient ratings, as measured by the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey, are also expected to be fed to that website, and those ratings will be tied to full reimbursement levels for physicians.
The clinicians and physicians who decline to be measured for "patient experience," in turn, will not receive a full reimbursement from Medicare.
And where Medicare treads, private insurers tend to follow, including the largest insurer in the state, Highmark Inc.
This month, Highmark began surveying patients and customers on their experiences with primary care physicians, hospitals and specialists, asking them about communication skills of doctors and nurses; whether the environment was "quiet and restful;" whether the food served (if any) was "appetizing and at the right temperature;" and other questions.
Patients will rate the physicians and their facilities on a one-to-five scale, and then Highmark will offer those ratings back to physicians, providers and customers.
Tom Fitzpatrick, vice president of provider contracting and relations for Highmark, said the new program is a tool for consumers that allows them to compare doctors and hospitals. The results of those surveys will not have a bearing on a physician's reimbursement levels.
At least, not yet. In the future, a physician's quality or care scores and patient experience scores could be used to group providers into tiers, with those providers ranked highly in quality, cost and patient experience getting preferential billing from Highmark. Or the scores could be bundled into Highmark's existing pay-for-performance program, Quality Blue.
The new measures give Highmark future "flexibility" in that regard, Mr. Fitzpatrick said.
He also said physicians and providers will be able to block up to two unfavorable reviews from public viewing.
UPMC, which operates both a hospital network and a health insurance plan, has been both collecting patient satisfaction data on the insurance end and receiving feedback on the provider end.
"There are so many different questions being asked of providers in so many different ways, [it can be] difficult for consumers to understand," said Dr. Steve Perkins, UPMC Health Plan's vice president of medical affairs. On the hospital side, Tami Minnier, UPMC's chief quality officer, said the data can be "overwhelming."
"If health care is really going to engage the consumer in a good way, we have to simplify it," she said. "You have to put it in a consumable fashion."
Mr. Shaller, the Minnesota consultant, said the Clinician and Group Consumer Assessment of Healthcare Providers and Systems surveys may seem subjective but are linked to years of health quality research.
"No physician or medical group likes to be scored on things," he said. But "this is not a continuation of the old patient satisfaction surveys. ... We've really gotten much better about assessing the patient experience" outcomes.
First Published July 22, 2012 12:00 am