Introduction

The United States spends more money on healthcare than any other developed country with more than $10,000 spent in total health expenditures per capita in 2016 (Sawyer & Cox, 2018). Healthcare consumes more of the gross national product year after year at a rate that is unsustainable. Our health outcomes, however, do not reflect these rising costs suggesting that the U.S. is not using its healthcare dollars efficiently. Leaders in health policy have looked to cost containment as a strategy to reduce expenses and improve profitability. One specific initiative to contain costs is to optimize how healthcare is delivered to patients and how providers are paid. James C. Robinson said, “There are many mechanisms for paying physicians. The three worst are fee-for-service, capitation, and salary,” (Robinson, 2001). Very broadly, fee-for-service models generally result in overutilization and capitation the opposite. Salary models undermine productivity. In these systems, competition in healthcare is not aligned with value for patients. By focusing on value for patient, we can create a system that improves quality of health that is based on health outcomes, which will ultimately lower costs as well (Porter, 2009).

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Quality refers not only to health outcomes, but also quality of the provider and of the care delivered; the latter two of which are subject to the patient’s perceptions. Most patients focus on the doctor-patient relationship while experts focus on effectiveness of treatments or health outcomes (Coleman, 2014). Patient satisfaction was not even factored into pay incentives until CMS started its Hospital Inpatient Value-Based Purchasing program (HVBP). Starting in 2012, Medicare began withholding 1% of its payments to hospitals to be doled out as bonuses to hospitals that score above average on certain measures. A large chunk of the scores are based on patient satisfaction measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (Centers for Medicare & Medicaid Services (CMS), HHS, 2011). The utility of these scores remains controversial since a happy patient isn’t necessarily one that received the best medical care and vice versa. Larger, tertiary care hospitals, especially those in urban areas oppose linking patient satisfaction to payment while smaller, community hospitals are more in favor. Teaching hospitals and larger hospitals tend to score lower than smaller community hospitals (Rau, 2011). CMS adjusts for some factors, but not all of them. Understanding the limitations of HCAHPS scores is an important step in determining the utility and validity of this value-based program.

Limitations of the HCAHPS Survey

Structural and Demographic Disparities

To start, safety-net hospitals tend to perform more poorly than other hospitals on almost every HCAHPS measure of patient experience. These hospitals are most likely to suffer from additional reimbursement cuts due to narrow operating margins and are disparately penalized for having lower scores (Chatterjee, Joynt, Orav, & Jha, 2012). In the first year of Medicare’s HVBP program, hospitals caring for more disadvantaged patients had significantly lower Medicare payment adjustments (Ryan, 2013). Academic medical centers, specifically, treat large number of disadvantaged patients because those centers tend to be the state hospitals or the large tertiary care centers in urban areas. These patients are likely to require multiple specialists and more complex coordination of care. Coupled with larger medical teams, this leaves room for more oversights and poorer communication likely resulting in a poorer patient experience.

Acuity of Care

Hospitals that treat more chronically ill patients for longer periods of time also tend to have worse satisfaction scores. One study found that in chronically ill Medicare patients, greater inpatient care intensity was associated with lower quality scores and lower patient ratings. Hospitals in regions with more-aggressive patterns of inpatient care are generally more inefficient in their resource utilization. Conversely, hospitals that use less inpatient care, tend have better scores in their chronically ill patients. Most of the questions of the HCAHPS survey are concerned with coordination of care and communication with patients. Regions with lower intensity care and greater patient satisfaction tended to have higher proportions of primary care providers who aid in care coordination both in and out of the hospital (Wennberg et al., 2009). Improving communication between PCPs and inpatient providers is critical in promoting conservative inpatient care. This not only improves care coordination from inpatient to the outpatient, but also reduces the number of providers involved in a patient’s care while in the hospital. More providers often lead to duplicate services, disorganized care, and higher chance of communication issues. Also patient often feel that when they have too many providers they are less likely to establish a rapport with any of them. Fewer providers and more thoughtful use of care leads to deeper provider-patient relationships and likely better patient satisfaction.

Patient Characteristics

Patient experience may also be confounded by factors that are not directly associated with their care. For example, patients may base their satisfaction scores on their health status regardless of the care they received, which can also explain why higher acuity hospitals have lower scores. One study showed that a better self-perceived health status was associated with greater patient satisfaction suggesting that characteristics external to the delivery of healthcare are also in play. Patient education, ethnicity, and primary language are among these characteristics that can influence patient satisfaction. Hospitals that treat a disproportionate percentage of non-English speaker, non-White, non-educated patients in large facilities report lower patient satisfaction scores (McFarland, Ornstein, & Holcombe, 2015). Both structural and demographic inequalities are often not adjusted for by CMS. Therefore, hospitals that serve indigent and elderly populations may be unjustly penalized under this HVBP reimbursement models.

Addressing the Entire Medical Team

Another limitation to the HCAHPS survey is its lack of focus on the patient-provider interaction. An analysis from the American Journal of Managed Care found that communication with physicians ranked fifth out of eight categories in order of degree of correlation with patient satisfaction. Communication with nurses, pain management and timeliness of assistance were the top three to correlate with overall satisfaction (Boulding, Glickman, Manary, Schulman, & Staelin, 2011). Patients value their interactions with the entire medical team and it is understandable that the members of the team with the most face time have the most influence over patient experience. However, when talking about outcomes, it is important to tie them to the physician order first and foremost.  Therefore, limiting the scope of the HCAHPS surveys to just the provider-patient interaction may provide greater insight into the aspect of care for which patient reported measures are most valuable.

Conclusion

Critically appraising the HCAHPS survey is an important step in validating its utility in the HVBP program. The biases and limitations of the survey show the consequences of using unadjusted models of scores to determine Medicare reimbursements. It also uncovers where hospitals can be held accountable for the things they can control while accepting that some patient perceptions may not change no matter what. Improving care coordination after discharge, reducing the size of medical teams, being thoughtful about utilization are all behaviors that any hospital can employ to improve their patient satisfaction. Teaching hospitals can invite social work students, pharmacy students and nursing students to be part of the medical team to create a better foundation and understanding of patient-centered care earlier on in their educations. Cleveland Clinic, for example, scored below average on 7 of 9 key patient-satisfaction questions according to their chief experience officer, Dr. James Merlino. They have analyzed their scores and improved physician communication by learning from their high-scoring physicians. According to the Dr. Merlino, the entire medical staff has attended a communication-training program taught by a team of peer physicians, which has already enhanced patient-physician conversations (Guadagnino, 2012). Any definition of high quality medical care must include the patient experience and if that is not always concordant with their outcomes then special care should be taken to understand why. Adjusting scores based on acuity of the hospital, as well as adjusting for teaching status and the demographics of the patients seen there is a start in recognizing nonrandom variance among satisfaction scores. CMS is taking these scores seriously for better or worse when distributing Medicare reimbursements, so a more productive strategy would be to focus on improving the patient experience. Listening carefully and employing empathy can go a long way, and at the end of the day, the value, in value-based medicine, should include the delivery of both high-quality and patient-friendly care.

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