Doctoring Health Care Health Care Reform

Just say no to linking patient satisfaction with dollars

I hope my patients are satisfied. This is everything. Improving the lives of people is why doctors do what they do. How much we help our patients is the metric. It’s the peg we hang our self-esteem on.

So yes, of course, patient satisfaction is really important.

But that doesn’t mean it’s a good idea to link it with dollars.

In fact, on a list of well-meaning but really dumb reform ideas, linking compensation of hospitals (or doctors) to patient satisfaction scores ranks near the top. Let me tell you why I think this way. It involves an important baddie—overtreatment.

Ever since reading this WSJ piece on the matter, I’ve thought about weighing in. Like so many good-intentioned ideas hatched in think tanks and cubicles, the problem is the unintended consequences seen in the real world.

A brief story: On my way out of the hospital the other day, I was called to the ER to see one of my patients. Due to privacy matters, I can’t tell specifics, but I can say that the problem related to his getting off “the program.” In this case, “off the program” refers to an utter failure to heed my warnings about over-indulging in substances that end in the sound “een.” (Say…caffeine and nicotine). Adding to this common digression was another shocker: non-adherence to Dr John’s well thought out less-is-more medical regimen. (Yes, I do occasionally prescribe medicine.)

So we had a nice chat about the problem at hand. Mustering all the strength I had left after a big day, I offered a few Mandrola-isms about avoiding intake of bad substances and adhering to a smartly prescribed regimen of evidence-based and inexpensive generic medicine. I made it clear that his health depended on him—not me.

Then I went out to tell the nurse and ER doctor, that not only could the patient be discharged, but that after our chat, his problem might be fixed.

I love visiting the ER. As medical blogs go, it offers a trove of potential topics. There was still time for a question.

I just had to ask the ER doc: “You have to do this a lot—talk to patients about the dangers of getting off the program?” He laughed. Looking around the ER that day, it was obvious the place was over-flowing with patients who had strayed far from “the program.” His partner, who overheard our conversation (all conversations in the ER are overheard by someone), added this: “Yeah, but now, with patient satisfaction scores, we have to be extremely careful not to make patients mad.” He was serious.

That got me thinking.

When finding fault with linking patient satisfaction scores with dollars, the knee-jerk reaction is to bring up the issue of opioid pain meds. So I did. “What if a patient isn’t happy with the amount or type of pain medicines you prescribe?” His answer came quickly: “That happens a lot, but in Kentucky, we are also on the hook if we give them too many.” (Ed note: Kentucky legislators recently passed a draconian bill limiting the prescription of opioids. It has had a chilling effect on the legitimate therapy of pain.)

Yesterday, Kevin O’Reilly wrote this comprehensive piece outlining the many problems with linking compensation to patient satisfaction scores. Earlier this year, Dr. Kevin Pho explained how patient satisfaction can kill. These are excellent discussions.

I’d add these two common occurrences from my world.

As Mr O’Reilly points out: medical care is not the same as customer service. For instance, I believe strongly in the importance of explaining and then implementing TLC—therapeutic lifestyle changes. That gets dicey. Asking or expecting patients to take care of themselves risks converting them quickly to the ranks of dissatisfied. A much easier road for the doctor is to avoid the elephant in the room–and simply write the prescription, order the MRI or refer the patient on to another specialist. This behavior will only worsen if we dis-incentivize doctors to speak the truth. We already have too much care.

Another example: The patient is referred for a well-reimbursed procedure. One approach that a specialist can take is to do the procedure. It’s evidence-based and everyone is happy and satisfied. Another approach is to discuss and implement a trial period of lifestyle changes (or other conservative measures) that, if embraced, could lead to avoiding the procedure. The problem with the conservative approach is that it risks poor satisfaction scores. Many want the easy fix. Not doing in our system is far harder than doing.

Bigger care, more care, riskier care–these are the reasons why I oppose using satisfaction scores to pay hospitals and doctors.

I’ll close with this warning—from the real world of healthcare–to policy makers:

What you incent with dollars will happen.


5 replies on “Just say no to linking patient satisfaction with dollars”

On the other hand, those of us who strongly prefer to avoid non-evidence-based medicine, and/or who have seen someone’s life turned upside down by an intervention cascade, are going to bristle and probably give you a lousy satisfaction score if you appear to be urging excessive tests and treatments upon us. So whether you’re conservative or aggressive, you can’t win with this model.

Last time I was sick, I found what I believe to be a decent primary care physician. She did try suggesting various risky screening tests that were unrelated to my problem, but acquiesced immediately when I refused. I would give her a high satisfaction score. Fortunately, she’s an independent practitioner and doesn’t have the sort of setup where she’ll be punished if, e.g., I don’t get “my” annual mammogram or take statins. That’s another gross intrusion into the doctor-patient relationship, and one that shows outright contempt for patients’ autonomy. No doctor should ever have to choose between coercing patients to submit to unwanted interventions or having her pay slashed.

Nice post John! And excellent reply from Jane. It clearly is tough. Sounds like a KEY is to follow what you both say – namely honestly convey to the patient what you believe to be the issues and suggest your best thought on what the therapeutic approach should be – yet (as Jane adds) always being open to joint informed-consent decision-making. During my years of practice – I always felt fulfilled using that approach and philosophy.

Unfortunately – the current reality is too much as John describes where “standards” are set by non-clinicians – and clinicians are “graded” by easy-to-measure criteria that do not necessarily reflect improved patient outcome (ie, HgbA1c values) – or in use of beta-blockers for patients with coronary disease without ever even allowing a space to indicate appropriate reasons for why the drug may not have been prescribed …. Don’t know that it will change until dollars take lower priority …

First, thanks for posting a good comment on the where I found your blog after another commenter posted a link.

Second, on patient satisfaction, the physicians and dentists to make us happy are those who realize that we want to be involved in decision making and want to know that our caregivers are keeping up with the literature, can and will answer our questions and are early adopters.

At the same time we don’t want to be the victims of defensive medicine or mostly unproductive and even counter productive “wellness” care, which usually isn’t.

What has amazed me for a long time is that so many people we know don’t seem to know how to hire anybody, including health care professionals. And they don’t ask many questions. It must be hard to deal with patients who treat you as a god and then don’t follow your advice.

But, then, as one who’s always been on a “program” of one kind or another, falling off the wagon is so easy and staying with the program is as difficult as breaking a bad habit, which is what staying with a program is.

This is where if no goal/objectives are set at the beginning of the relationship/project you will never know when you have objectively met those requirements. I know this is the businessperson in me talking but I would like to have such a discussion when I start any relationship with my medical staff. None of my medical staff has ever asked what my goals are and for that reason would fail any satisfaction question. Dean

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