The ACA made many changes to Medicare. One of them involves linking part of hospital pay to patient satisfaction.
In an Atlantic magazine essay adapted from her new book, “The Nurses: A Year of Secrets, Drama, and Miracles With the Heroes of the Hospital,” Alexandra Robbins argues that hospitals are missing the point: the way hospitals are defining, measuring and achieving patient “satisfaction” is not advancing the quality of care.
Robbins overstates that the amount of Medicare payments tied to patient satisfaction and understates the role of outcomes (more on Medicare’s Hospital Value-Based Purchasing later). But her essay is provocative and worth thinking about for those of you who cover the hospital industry or your local hospitals, and how they are changing under the Affordable Care Act.
I haven’t read her whole book, which is a narrative built around the experiences of several nurses. But in the Atlantic essay, she makes the case that hospitals are making wrong-headed decisions – and nurses then get the blame for “satisfaction” gaps that have nothing to do with nursing. She writes that hospitals are striving to be four-star hotels, with nurses expected to be the bedside equivalent of a personal butler.
The patient satisfaction requirements date back to Oct. 2012 (the start of federal fiscal year 2013) when, under the Affordable Care Act, 1 percent of total hospital Medicare reimbursement was cut. But hospitals could get pay restored if they had high patient satisfaction scores, meeting certain care standards. Top-performing hospitals could get bonuses. Robbins argues though that the ways hospitals are measuring and rewarding “patient satisfaction” isn’t translating into good medical care. A patient who is highly satisfied with, say, the amount of pastrami on his lunchtime sandwich may still be dead in an hour.
Hospitals use a survey known as Hospital Consumer Assessment of Healthcare Providers and Systems (fact sheet here). HCAHPSs was developed by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality.
According to AHRQ, “The HCAHPS survey contains 21 patient perspectives on care and patient rating items that encompass nine key topics: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, quietness of the hospital environment, and transition of care.” It has 32 questions, and it also include some demographic information to adjust the patient mix. Some of those “satisfaction” measures do pertain to quality of care, and some do involve nursing. But Robbins says the balance is off kilter.
She examined Medicare provider data for thousands of hospitals, and found those that perform below average on three or more patient outcome categories. “These are hospitals, in other words, where a higher number of patients than average will die, be unexpectedly readmitted to the hospital, or suffer serious complications. And yet two-thirds of those poorly performing hospitals scored higher than the national average on the key HCAHPS question; their patients reported that “YES, [they] would definitely recommend the hospital.”
Patients have complained on the survey, which in previous incarnations included comments sections, about everything from “My roommate was dying all night and his breathing was very noisy” to “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.” An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery). “Many patients have unrealistic expectations for their care and their outcomes,” the nurse said.
Robbins also points to research that satisfied patients are also heavier consumers of care – and we all know by now that more care isn’t always better care, or necessary care. Worse, she wrote, “the most satisfied patients were significantly more likely to die in the next four years.”
She cites a study by Joshua Fenton, a professor at the University of California, Davis, who suggested that this higher utilization could reflect that “doctors who are reimbursed according to patient satisfaction scores may be less inclined to talk patients out of treatments they request” – or to talk about things that a patient might find uncomfortable, such as smoking or substance abuse.
Once hospitals are in this satisfaction trap they may be rushing to create “VIP patient loyalty programs’ or valet parking, instead of really focusing on improving the quality of care. And they are training nurses to focus on “customer service” not patient care. She cites an anecdote posted on a nursing blog in which hospital that started using microwaved meals then blamed the patient complaints on the nurses’ failure to make the food sound good.
If you read some of the trade publications that focus on hospitals, you’ll find a different perspective than Robbins, but you will see quite a bit of stress on “customer service.” Robbins may be overstating the case, but she does pose some questions that are worth examining. Talk to your local hospitals, and the state hospital association. If it’s unionized, talk to the nurse’s union or other nurses’ associations in your area. Compare satisfaction rates to the national rankings and ratings the hospitals get on various publicly-available ranking sites (which don’t always agree with one another). Look at “satisfaction” against “safety” measures.
And here’s a little more about Hospital Value-Based Purchasing. This is a program phased in from FY 2013-17 under the ACA. (HHS Secretary Sylvia Burwell in early 2015 announced a much broader based and rapid switch to an overall value based payment approach), with 30 percent of payments linked to alternative payment models such as Accountable Care Organizations. That’s separate from the specific, narrower Hospital Value-Based Purchasing underway now. Hospitals also face penalties under separate programs designed to reduce avoidable readmissions and hospital-acquired conditions.
Robbins’ Atlantic essay incorrectly states that HHS “decided to base 30 percent of hospitals’ Medicare reimbursement on patient satisfaction survey scores” in 2012 under the ACA’s VBP. In the next paragraph, it correctly states that the policy was withholding 1 percent of Medicare reimbursement – not 30. (It phases up to 2 percent in 2017). Hospitals, as she noted, can earn some of that back or get bonuses based on satisfaction. But the entire 1 percent isn’t based on the satisfaction survey – it’s 30 percent of that 1 percent in year one, and patient satisfaction actually counts less by 2017. Patient satisfaction is one of four domains.
Clinical processes and outcomes also matter, with outcomes gradually becoming the dominant factor. Here’s a good chart from the Advisory Board laying out the four domains and how the balance changes over the four years. CMS also has a fact sheet about patient surveys and VBP, and a very detailed FAQ for the industry. Here’s a Modern Healthcare article describing the program’s impact on the industry as of late 2014.