Saturday, March 31, 2012

Another Managed Care Approach Bites the Dust

Managed care companies have always been big on patient satisfaction.  There are a number of reasons for this the largest one being that they hope to replace medical approaches to healthcare with business approaches. That involves applying paradigms used in automobile manufacturing and customer service such as patient satisfaction surveys. It also involves applying business strategies to those surveys so that any particular business will look as good as possible when it is advertised. It is no accident for example that all the hospitals in your area are "five-star hospitals" or "highly rated" if the companies involved know how to game the system, the deck is stacked in favor of high patient satisfaction ratings. That can be done by combination of survey structure, survey timing, or scripting. During scripting the patient is exposed to a number of statements by a healthcare provider who has been trained in how to do this so that their statements closely match questions on the patient satisfaction survey. It is very difficult for a person to say they were never provided with information if they received carefully scripted information five minutes before they took the survey.

Another advantage of patient satisfaction surveys is that they can be used as leverage against physicians. Managed care companies are always on the lookout for new ways they can reduce reimbursement to physicians. They already have an incredible amount of leverage with the so-called RVU-based compensation system but apparently that is not enough.  In many cases a percentage of the physicians reimbursement is linked to patient satisfaction surveys. The more satisfaction, the greater the reimbursement. The irony is that in many cases, the money used for that incentive is a "hold back" or percentage of what the physician has actually earned. They will not get their full reimbursement unless they have adequate patient satisfaction ratings. The problem with that system should be obvious, but it was made even more obvious by a recent article in the Archives of Internal Medicine.

In that study, the authors looked at a large sample of 51,947 patients over a timeframe of seven years. They focused on how their satisfaction ratings correlated with outcome measures. They found that the patients in the high satisfaction group had a 8.1% greater healthcare expenditure, 9.1% greater medication expenditure, and a 26% greater mortality risk.  The most satisfied group was at less risk for an emergency department visit but had higher inpatient expenditures.  The authors point out that patient satisfaction ratings correlate most highly with whether or not the physician fulfills the expectations of the patient.  That could lead to a lower threshold for elective admissions to hospitals, more invasive testing, and less discriminatory prescribing practices.

Their overall conclusion is that we do not know enough about patient satisfaction ratings and the implications for quality care. They make an excellent point about the need for physicians to discuss problem areas with patients “including substance abuse, psychiatric comorbidity, nonadherence, and the risks of requested but discretionary tests or treatments.”  Those discussions may not be conducive to high patient satisfaction ratings.  They also point out that these discussions necessarily take time. As I have previously pointed out, the time for discussions and clinics has practically been rationed out of existence.

I thought that this was an excellent article overall that points out significant problems with business approaches to the practice of medicine. Rating a doctor like you would rate your car salesman creates a unique set of problems that businesses and the government have no interest in addressing.  Ratings within healthcare organizations linked to physician "incentives" may be no more reliable than doctor ratings on Internet sites.

George Dawson, MD

Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures,and mortality. Arch Intern Med. 2012 Mar 12;172(5):405-11.

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