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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Does Linking Payment to Patient Satisfaction Harm or Help?

I don’t want my epitaph to be “The patient was satisfied with her hospital experience but died from poor care.”

Diana Mason, PhD, RN

This came to my mind last fall, during a graduate nursing course I teach in health policy, when we were studying value-based health care. A student who worked in a financially stressed hospital serving a poor community said the administration encouraged employees to ensure that patients would give high marks on a patient satisfaction survey. After all, those scores were linked to enhanced Medicare payments. The student said physicians felt compelled to prescribe opioids for “drug-seeking” patients and order unnecessary tests or antibiotics, for example, at patients’ requests. Nurses and other personnel were being trained in “customer service,” while nurse–patient staffing ratios had gotten worse.

Medicare’s Hospital Value-Based Purchasing (VBP) Program links payment to achieving the “triple aim” in health care—better patient experiences, better health, and lower costs. The Affordable Care Act (ACA) requires tying VBP to patient satisfaction as a measure of the “patient experience” by using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Data from these surveys are reported on the Medicare Hospital Compare website, allowing people to decide which hospital to use, if a choice exists in their community.

Few would doubt that this experiment in reforming our costly, poorly functioning health care system is necessary. But is it doing more harm than good?

Patients’ Experience of Care

The 32-item HCAHPS survey, rigorously developed as a joint effort of the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services (CMS), measures patients’ perceptions of their experience with care during a recent hospitalization. The survey was voluntary at its launch in 2006, then required for hospitals operating under the inpatient prospective payment system to receive their full annual payment update. Subsequently, the ACA incorporated it into the payment incentive calculations in the Hospital Value-Based Purchasing Program, applying more pressure on hospitals to attend to patients’ experiences of care.

For 2015, 30% of a hospital’s performance score used to calculate its Medicare incentive payment is based upon the HCAHPS; in 2016, it decreases to 25%, as outcomes and efficiency measures become more heavily weighted.

Available in 6 languages, the survey includes questions on care from nurses and physicians; the hospital environment (cleanliness and noise); specifics on care such as pain management, hospital discharge, and care transitions; demographics; and overall hospital ratings. Despite explicit questions on nursing, there is objective and anecdotal evidence that nursing care is reflected in many of the remaining questions and may drive overall patient satisfaction with hospital care. In addition, physician communication, especially respect and listening, has been identified as a key factor in patient satisfaction ratings.

Hospital Responses

Because 1% of a hospital’s Medicare payments in 2015 are being linked to its performance (it will increase to 2% in 2017), hospitals are taking steps to increase their HCAHPS ratings. Many are giving unit-level HCAHPS scores to staff, usually quarterly, with the goal of engaging them in improving pain management, noise levels, or communication with patients (some have argued that low survey response rates from patients make these findings unreliable). One hospital has “HCAHPS performance prizes” that consist of lunches for housekeeping staff and financial bonuses for physicians, nurse managers, and other administrators.

To improve HCAHPS scores, some hospitals now have “chief patient experience officers.” Some mandate that clinicians attend workshops on compassion and communicating with patients, require rounding by senior leaders, or use other strategies that could actually improve interactions with patients and families and, therefore, outcomes. There is some evidence that interventions such as these can improve patient satisfaction and hospital revenues. One study found that “compassion training” for physicians made a difference in patients’ ratings and recommendations to others.

The evidence on whether HCAHPS scores are linked to clinical outcomes is mixed. For example, one study found that higher patient satisfaction is associated with lower complication rates. Other evidence finds that patient satisfaction ratings are unrelated to surgical mortality and morbidity rates. But physicians are expressing their concerns about such ratings and the extent to which clinicians should be driven to satisfy patients vs provide evidence-based care. A 2012 study found that patients who are highly satisfied with their physicians have lower rates of emergency room use but higher costs and rates of hospitalization and death. And concerns about the pain management portion of the HCAHPS have led the American Medical Association to recommend that CMS stop using it until its validity can be confirmed.

Some nurses are being scripted on how to talk with patients, but most I spoke with resent the idea. One staff nurse on a transplantation unit told me that nursing staff were mandated to go through 2 hours of “empathy training” using scripts. The nurse viewed the scripts as ways to apologize for a hospital’s failures to manage resources well, telling me she was expected to apologize to the patient if he had to wait for pain meds because she had too many patients that day, or for the hospital’s poor food, or for a delay in the physician writing the discharge order. She reported that her hospital netted $356 million in 2013 (more than 8% of its revenues), but the nurse-patient ratios have gotten worse.

She and other nurses are deeply concerned about the return of inadequate staffing. Research shows that nurse staffing and the work environment are instrumental in improving the rates of satisfied patients, complications, mortality, and staff turnover, as well as saving money.

Looking Forward

Many clinicians object to the new customer-service orientation of hospitals, but evidence shows that HCAHPS scores have risen in the first 5years of the survey’s use. Clinicians’ concerns about institutional efforts to improve patients’ perceptions of their care may reflect the early state of our hospital performance metrics. As the weight of clinical outcomes in Medicare’s Hospital Value-Based Purchasing Program increases from 30% of the hospital’s performance score in 2015 to 45% in 2017, perhaps hospitals will reduce their reliance on scripts and ways to fool patients into thinking they are getting excellent care.

Or perhaps CMS and other payers should also require reporting on the satisfaction of physicians, nurses, and other staff with the care given. Nurse satisfaction with the work environment is part of the application for Magnet Hospital designation (for excellence in nursing care) by the American Nurses Credentialing Center; a 2014 study found that Magnet hospitals have higher levels of patient satisfaction than non-Magnets.

If I am hospitalized, I want health professionals who have my best interests at heart and are skilled at communicating well, responding when care is delayed, engaging me in my care, and preparing me to care for myself at home. But I also want the hospital to ensure adequate staffing and cleanliness, to decrease delays in care, and to lower rates of nosocomial complications—not train my nurses and physicians to be skilled in apologizing for poor, inefficient, unsafe care.

About the author: Diana J. Mason, PhD, RN, is the Rudin Professor of Nursing and Codirector of the Center for Health, Media, and Policy at the Hunter College; Professor at the City University of New York; and President of the American Academy of Nursing.