This paper examines area of quality and patient satisfaction linked to reimbursement in the article by Nanda, Malone and Joseph (2012), where they describe strategies for changes needed in Health Care Design in response to the Affordable Care Act. The article notes that the main shift in reimbursement model will be tied into financial reward for patient experience as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) which aligns with the Institute of Medicine (IOM) patient centered care, one of their quality improvement aims.
The PRWeb (2013) in Washington DC reports the reimbursement as follows “the reduction in hospital revenue, based on performance, may be 1. 0% in 2013, 1. 25% in 2014, 1. 5% in 2015, 1. 75% in 2016, and 2% for 2017 and subsequent years. For the year 2013, this represents $1 billion at stake”. Patient satisfaction is strong metric for measuring performance.
My reaction to this is simply that measuring patient satisfaction probably the least reliable way of measuring quality, especially when we are asking for responses from patients that addresses an experience that is personal and is at most level impacted by emotions, fear and possibly changes in their lives related to illness, surgery and other medical issues. Given the spectrum of patients in United States we have not accounted for cultural differences, expectations and compliance with care.
Are the patients responding to the surveys which measure satisfaction and experience responding based similar expectations and outcomes? In the study done by Wall, Tucker et al (2013) from John’s Hopkins University they found that “Patient health care satisfaction fully mediated the relationship between patient- perceived cultural sensitivity of front desk office staff and patient treatment adherence. The patient satisfaction and cultural sensitivity variables explained 10% of the variance in patient treatment adherence.
Training front desk office staff in patient- centered culturally sensitive health care may improve patients’ health care satisfaction and treatment adherence. ” Another study by Mc Gregor, Dore et al (2013), An Exploration of Patient’s expectation and Satisfaction with Surgical Outcomes finds “that differences existed in the satisfaction with outcome between the two surgical populations, with discectomy patients clearly having higher satisfaction levels. Few studies have explored the influence of surgical procedure apart from Toyone et al.
(2005), who also noted higher levels of satisfaction in the discectomy population with little difference in pre-operative expectation between the two groups. It is not clear from either study why this difference occurs; however, in our earlier outcome study it was observed that patients having discectomy did achieve better outcomes than those having decompression which may relate to the underlying physiological process and the differences in age between the two populations”(p2841-2842).
Aside from culture and expectations, Patient surveys are not separated by age groups or diagnosis which based on the orthopedic patients in the surgical study there are differences in responses even by types of procedures done. Elective surgery is as standardized as you can get in patient’s journey through the healthcare process. This highlights how difficult it will be to measure patients’ satisfaction in a global way and why I do not think it should be tied into reimbursement.
Another reason for not using satisfaction score in determining reimbursement is related to the way in which the surveys are 1) administered and 2) the way peoples’ responses change over time. Zaller and Feldman (1992), A Simple Theory of Survey Responses addresses and the American Statistical Association (ASA) Psychology of Survey Response Webinar (2010) both address the way in which surveys are answered. A response from a person will vary over short time frames from one week to six months.
HCAPHS requires that the patients be surveyed between 48 hours to six weeks after their discharge which is within the studies for a change in the way the patient responds. In addition the study also addresses the fact that people tend to be more favorable on verbal (telephone) interviews. HCAHPS allows for either mail or telephone survey or a combination of both. Another factor in survey responses is related to encoding. Memory of events can be coded by a person based on triggers and if those triggers are not present when the question is asked the recall may not be accurate.
If our patient satisfaction metric is inconsistent as noted in the studies reviewed then to link them to reimbursement is essentially going to plunge Healthcare into a financial crisis based on the proposals by made by Nanda, Malone and Joseph (2012) •Reduce average size of units – increase direct caregiver time spent with patients –this is loss of beds with more staff to meet the time spent criteria.
•Decrease multi-tasking – can require more staff, specialization amount staff duties thus increasing the number of encounters and possible chances of poor reviews •Improved technology – a must but I do agree but the cost to implement, train and upkeep is huge.
Their proposals require spending from what would be an already decreased revenue flow on improving patient satisfaction. Aside from reasons given why patient satisfaction is not a good metric to tie into reimbursements the way of getting patients’ input does not account for patients who do not respond but are highly satisfied, patients who do not understand the question but check and move on as a chore, patients who differ in the way they understand the question, elderly patients who ask family members to fill the survey on their behalf.
We are also excluding a subset of patients – HCAPHS excludes the following patients •“Patients discharged to hospice care •Patients discharged to nursing homes and skilled nursing facilities •Court/Law enforcement patients (i. e. , prisoners) •Patients with a foreign home address (excluding U. S. territories—Virgin Islands, Puerto Rico, and Northern Mariana Islands) •“No-Publicity” patients •Patients who are excluded because of rules or regulations of the state in which the hospital is located” (p 4).
This subset are probably the subset that should give feedback as they are the patients who have more needs and accommodations and can speak to the adaptability of a facility in providing quality care on an individual basis. I believe we should obtain patient satisfaction scores and use them based on more geographic, demographic, diagnosis and cultural way to improve care to groups with specific needs, away from one track fits all. Perhaps payment bonuses tied into the patient satisfaction score and improved results for groups, not for the overall score of all patients across the spectrum of hospitals.
Or rate reimbursement on measurable outcomes as proposed such as decubiti, infections and falls, and gives an annual publicized lettered grade for patient ratings A through D. I feel that reimbursement based on patient satisfaction is a financial gamble, even when the care in the Healthcare forum measured is excellent, for all the reasons stated given the variables in collecting data on patient satisfaction.
I am convinced patient satisfaction is a moving target and completely inaccurate as a tool of measurement for reimbursement. With organizations chasing satisfaction scores we have ‘the tail wagging the dog’. References Nanda, U. , Malone, E. , Joseph, A. (2013). The Impact of Affordable Care Act on Healthcare Design retrieved from http://www. contractdesign. com/contract/design/The-Impact-of-the-Af-9712. shtml. Mc Gregor, A. H. , Dore, C. J. et al (2013).
An Exploration of Patients’ Expectation of and Satisfaction with Surgical Outcome, Eur Spine Journal 22, 2836-2844. PRWeb (2013, August 26). PPACA Hospital Reimbursements Impacted by HCAHPS Patient Satisfaction: RateHospitals. com Empowers Patients to Define Healthcare’s Future. Retrieved from http://www. prweb. com/releases/HOSPITAL/HCAHPS/prweb11059500. htm HCAHPS Fact Sheet (2013, August).
Retrieved from http://www. hcahpsonline. org/files/August%202013%20HCAHPS%20Fact%20Sheet2. pdf ASA Webinar (2010, February 9). The Psychology of Survey Response.
Retrieved from http://www. amstat. org/sections/srms/ThePsychologyofSurveyResponse. pdf Wall, W. , Tucker, C. M. et al. (2013). Patients’ Perceived Cultural Sensitivity of Health Care Office Staff and Its Association with Patients’ Health Care Satisfaction and Treatment Adherence. Journal of Health Care for the Poor and Underserved, 24 (4) 1586-1598. Zaller, J. , Feldman, S. (1992). A Simple Theory of the Survey Response: Answering Questions versus Revealing Preferences. American Journal of Political Science. 36 (3) 579 -616