Legislated mints on the pillow

In the 19th century, Florence Nightingale began collecting data to evaluate medical outcomes. Using data to improve surgical outcomes has since vastly improved quality of care.1 Recently, patient satisfaction data have been made available to the public and are now being collected using the Hospital Consumer Assessment of Healthcare Providers Survey (HCAHPS), a government-run evaluation centered on the following topics: communication with physicians and nurses, hospital staff responsiveness, pain management, communication about medicines, discharge information, hospital cleanliness, and hospital quietness.2 With health care reform, such survey results will affect hospitals, and thereby surgeon reimbursement. Hospitals are at risk of losing up to 2 percent of their funding by 2017.3

Like many idealistic, well-intentioned endeavors, these surveys have real-world consequences. Altering pay based on subjective surveys will increase costs to the medical system with no evidence that these surveys will improve the quality of care.

Subjective factors

According to Jean Moody-Williams, Director of the Quality Improvement Group, Centers for Medicare & Medicaid Services, “The majority of (survey) measures…have to do with communication…things that are universal regardless of the state of your facility.”4 But in fact, HCAHPS responses are not universal. A major dilemma in citing satisfaction as a reliable measure is that the patient population is vastly diverse. People interpret questions differently and have varying criteria for what determines a desirable hospital experience.

Researchers found significant disparities in HCAHPS ratings related to race, ethnicity, and socioeconomic status.5 Others found that not only were there significant differences in ratings between Hispanic and non-Hispanic patients, but there were significant differences among Hispanics depending on their country of origin.6 The mode of survey further complicates results. Anastario and colleagues found that modes of surveying that increase the proximity of respondents to the interviewer/visit produce more favorable results (for example, telephone/handout surveys are more favorable than mail-in).7 The very fact that there is a difference in results among these survey modes raises the question of their validity.

Where’s the value?

The Institute of Medicine (IOM) defined quality as the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with the current professional knowledge.”8 In our current health care market we aim to achieve value, which is a function of increased quality and decreased cost.9 However, using HCAHPS to alter pay actually increases costs without evidence that it improves quality. According to Kevin Slave, chief executive officer of East Orange Hospital in New Jersey, the facility has “some of the best infection-control outcomes…but if you looked at the equipment and furniture, it maybe is not as shiny and new as in a suburban hospital.”4 East Orange Hospital has begun upgrading its televisions to flat screens to lift scores.4 Grady Memorial Hospital, Atlanta, GA, reportedly invested approximately $4 million on upgrades in an effort to raise its survey scores.4 Collecting and analyzing the survey data is also expensive and requires trained personnel.9

Such increased resource use has not been shown to improve desired health outcomes. To the contrary, a study published in the Archives of Internal Medicine showed that the most satisfied patients actually had a 44 percent higher mortality rate. The most satisfied patients also spent 9 percent more on prescription drugs and had an 8 percent increase in overall health care spending in comparison with less satisfied counterparts.10 Although many physicians already have trouble denying patient requests, linking patient satisfaction to pay may increase the use of imaging studies, prescription drugs, and other tests not medically warranted but that patients demand, thereby increasing defensive medicine and overall system utilization.11

Satisfaction, not quality

Adoption of the mantra that “the customer is always right” in medicine can have serious consequences that extend beyond added costs. For example, a patient or his or her family may not understand the need for early tube feeding, ventilator support, noisy oxygen saturation alarms, or aggressive respiratory/physical therapy, but withholding any of these in hopes of better comfort could be detrimental. Although the IOM definition of quality encompasses outcomes “consistent with the current professional knowledge,” a 2004 poll found that respondents cared more that their physicians listened to their concerns and questions than whether their physicians were up-to-date on the latest medical research and treatment.8,12 This further illustrates the difficulty in equating patient satisfaction with quality of medical care.

It is also important to note that monetary incentives to provide quality patient care already exist. Good patient relationships decrease lawsuits.13 Patients can choose providers based on widely available Internet ratings, and surgeons must provide good interpersonal care to maintain business. Personal recommendations have shown to be 2.6 times more likely to influence a purchase in health care than in other industries.14

Adjusting pay based on HCAHPS results has been touted as a means for transforming patients into consumers in a free-market economy—so let us consider this concept’s applicability to other consumer markets.3 If my heating repair technician tracks mud through my house, can I decide to slash payment even though my heat is fixed? No. I have the option of reporting it, or I can leave a negative online survey, but I cannot reduce payment after the service has been rendered. In a free-market economy the consumer’s power is that he or she has a choice, not a tail-end regulation.
In an age of evidence-based medicine, I question how a policy can be enforced with such a paucity of evidence that its implementation will improve health care value. HCAHPS is only a part of the current health care reform’s pendulum swing, and similar to many paradigm shifts, the swing will likely overshoot before eventually settling on a rational solution.

In The Icarus Deception: How High Will you Fly?, Seth Godin writes, “When we humanize the person at the other end…we grant them something precious—personhood.”15 As physicians, we have felt that connection with our patients. It is always unique and cannot be contrived. It is an experience in humanity that should never be disparaged. For government to legislate exactly what factors lead to that immeasurable connection taints the physician-patient relationship with impersonal checkboxes, while adding costs to an already expensive and complex medical system with no evidence that it will increase value in American health care.


  1. Wascher R. Surgery, NSQIP, complications, and death. Men’s Daily News. October 4, 2009. Available at: http://mensnewsdaily.com/2009/10/04/surgery-nsqip-complications-death/. Accessed April 1, 2013.
  2. Centers for Medicare & Medicaid Services. HCAHPS hospital survey. Available at: http://www.hcahpsonline.org. Accessed April 1, 2013.
  3. Meyer Z. Medicare payments tied to patient surveys. USA Today. December 24, 2012. Available at: http://www.usatoday.com/story/money/business/2012/12/24/hospitals-satisfaction-surveys-medicare/1788833/. Accessed April 1, 2013.
  4. Adamy J. U.S. ties hospital payments to making patients happy. Wall St J. October 14, 2012. Available at: http://online.wsj.com/article/SB10000872396390443890304578010264156073132.html. Accessed April 1, 2013.
  5. Elliot MN, Haviland AM, Kanouse DE, Hambarsoomian K, Hays RD. Adjusting for subgroup differences in extreme response tendency in ratings of health care: Impact on disparity estimates. Health Serv Res. 2009; 44(2):542-561.
  6. Weech-Maldonado R, Fongwa MN, Gutierrez P, Hays RD. Language and regional differences in evaluations of Medicare managed care by Hispanics. Health Serv Res. 2008;43(2):552-568.
  7. Anastario MP, Rodriguez HP, Gallagher PM, Cleary PD, Shaller D, Rogers WH, Bogen K, Safran DG. A randomized trial comparing mail versus in-office distribution of the CAHPS Clinician and Group Survey. Health Serv Res. 2010;45(5):1345-1359.
  8. Lohr KN, ed. Medicare: A Strategy for Quality Assurance, Volume I. Washington, DC: National Academy Press; 1990.
  9. Ireson CI, Ford MA, Hower JM, Schwartz RW. Outcome report cards: A necessity in the health care market. Arch Surg. 2002;137(1):46-51.
  10. 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;172(5):405-411.
  11. Campbell EG, Regan S, Gruen RL, Ferris TG, Rao SR, Cleary PD, Blumenthal D. Professionalism in medicine: Results of a national survey of physicians. Ann Intern Med. 2007;147(11):795-802.
  12. Bright B. Doctors’ interpersonal skills are valued more than training. The Wall Street Journal. September 28, 2004. Available at http://online.wsj.com/article/SB109630288893728881.html. Accessed April 1, 2013.
  13. Moore PJ, Adler NE, Robertson PA. Medical malpractice: The effect of doctor-patient relations on medical patient perceptions and malpractice intentions. West J Med. 2000;173(4):244-250.
  14. Berry E. Satisfaction scores seen as crucial to physician success. American Medical News. August 6, 2012. Available at: http://www.amednews.com/article/20120806/business/308069949/6/. Accessed April 1, 2013.
  15. Godin S. The Icarus Deception: How High Will You Fly? New York, NY: Portfolio/Penguin; 2012.

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