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.

NYTimes Tells You How to Rate Your Doctor

The New York Times has a feature (see first reference) that discusses why the number of Internet reviews of physicians is sparse and the quality is poor.  The main contention is that people are too intimidated to rank physicians. The author ignores the profit motive of all the sites as a potential conflict of interest and leaps to the conclusion that the AMA speaks for most physicians even though only about 29% of physicians are members of the AMA.  He also describes physicians as "untouchable" when in fact at least 20% of physicians can be expected to be sued for malpractice during their lifetime and malpractice lawsuits have resulted in entire specialties migrating from a particular state. That is hardly what I would describe as "untouchable".  He is openly critical of the president of the AMA suggesting that anonymous, undocumented, and unverified reviews are probably not the best source for a physician recommendation.  He quickly invalidates "disproportionately positive reviews" on some websites is the product of an "unquestioning mindset".

The worst part of the article is leaping ahead to the Medicare initiative and their physician report card. Nevermind the fact that the risk adjustment concern by the AMA is legitimate.  Nevermind the fact that there is really no valid way to compare physicians at this point in time.  Nevermind the fact that there are political interests at play in particular the managed-care industry and how they can potentially game the system in favor of their principles. The author basically is encouraging people to go full speed ahead.

The result of that experiment is fairly predictable. The only thing I am hoping is that Google will come up with a way to prioritize the relevant information about physicians such as where they really practice and how to get a hold of them instead of the pages and pages that you currently encounter when you are trying to find a physician.

The AMA doesn't give much better advice in their recent edition of the amednews.  In a piece entitled "Physician rating website reveals formula for good reviews", their first suggestion was to not have a patient waiiting for more than 15 minutes and no more than 10 minutes in the exam room.  I can't think of any practice where the physician has that kind of control over their schedule - even if they postpone all of the documentation and stay for several hours after the clinic closes to get it done.  The business experts observed:  "overall ratings were based on time in the waiting room and the exam room -- rather than perceived clinical quality".  Keep that in mind when you are looking at online ratings of physicians.

I would suggest an experiment of my own that I have conducted several times with a high degree of success.  Imagine that you have a serious medical condition that requires a high risk procedure and you want to find the best physician to help you.  Your search process will involve the Internet, but it does not involve looking at any of the ratings you find when you search on a physician's name.  What do you do?

I will come back and answer that at a later date and discuss how that needs to be modified when you are looking for a psychiatrist.

George Dawson, MD

Ron Lieber.  The Web Is Awash in Reviews, but Not for Doctors area Here's Why. New York Times March 9, 2012

Pamela Louis Dolan.  Physician rating website reveals formula for good reviews.  amednews. Feb. 27, 2012