Patient Satisfaction and Care Quality: Problems and Predictions

Value-based reimbursements and incentives are typically measured by what is dubbed the “triple aim”: improved patient health, decreased cost of care, and higher patient satisfaction scores.

But a new study brings up the question: Should patient satisfaction scores really play into that equation?

Researchers at the University of California, Davis, surveyed more than 50,000 people nationally from 2000 to 2006 to determine how their level of satisfaction measured up to their health status.
Satisfaction measures were based on the Consumer Assessment of Health Plans Survey, which evaluates patient satisfaction across five dimensions, ranging from physician communication to health plan customer service.

Patients were asked questions including how often their physician listened carefully to them, showed respect for what they had to say, and spent enough time with them. They also rated their healthcare providers on a scale of zero to 10.

Not surprisingly, the researchers found that patients who reported the highest satisfaction were also spending the most money on healthcare. Of course, that correlation makes it seem nearly impossible for physicians to fulfill the triple aim of lowering healthcare spending while increasing patient satisfaction.

“I can definitely see that patients that like their relationship with their physician are more likely to be more active users of the healthcare system at large - which is the correlation pointed to in the study… and they are more likely to be compliant with physician treatment protocols, which are likely to include pharmaceuticals and more robust diagnostics,” George Taylor, president of Beyond Feedback, a firm that helps practices gain insight into patients’ experiences, said in an e-mail to Physicians Practice.

What’s more surprising is that more satisfied patients also had a higher likelihood of hospital admittance and higher mortality rates (again, the opposite of the triple aim target of improved quality of care).

For every 126 people who died in the most-satisfied group of patients, only 100 in the least-satisfied group died, according to the survey. The association between higher patient satisfaction and mortality remained significant in an analysis that excluded patients with poor self-rated health and three or more chronic diseases.

Taylor, who is also a Practice Notes blogger, said the correlation between mortality and satisfaction, left him “scratching his head.”

In a 2010 USA Today op-ed, well-known physician blogger and founder of KevinMD.com Kevin Pho noted the pressure to please patients might be making it hard for physicians to refuse patient requests that could result in poorer health.

“Quality healthcare sometimes means saying ‘no’ to patients, denying them habit-forming pain medications that can feed an underlying, destructive drug addiction, or refusing to order unneeded CT scans that can facilitate harmful radiation exposure,” Pho wrote.

The University of California study authors suggest that physicians may avoid discussing issues with patients that will make them uncomfortable, such as substance abuse issues, non-adherence to treatment plans, etc. Again, this could be a contributor to poor patient health.

Taylor said the study raises a “significant” issue - that the medical industries measurement of patient satisfaction is conceptually behind the times.

“We’re measuring patient satisfaction because that’s what we’ve always done, but I think we’re likely over time to find that ‘satisfaction’ itself is not the best predictor of outcomes,” he said. “My suspicion is that over time as we get more sophisticated with our measurement tools, our key metrics (like patient satisfaction) will change to something that can be causally connected with outcomes,” like how compliant patients are with their medical treatment plans, and how satisfied patients are with their current health conditions.

But the way in which satisfaction is likely to be measured is not the only thing changing. The way in which patients measure their level of satisfaction may be changing as well.

A lot has changed since the study took place between 2000 and 2006, notes James Doulgeris, Practice Notes blogger and manager of the healthcare consultancy division at HCP Associates. At that time, overutilization of healthcare services was more affordable for patients and deductibles and co-pays were far less expensive.

In an e-mail to Physicians Practice, Doulgeris said today, patients tend to shop around, question the necessity of tests or labs, and/or simply forgo tests or care altogether. In fact, Doulgeris said, those are primary reasons the growth in healthcare expenditures was so low in 2009 and 2010.

Perhaps if the study were conducted now, the most satisfied patients would be the ones who visited physicians who prescribed less costly medical care. And perhaps that means patient satisfaction might actually fit in well with the “triple aim” target of lowering healthcare costs.

What do you think of patient satisfaction? Should it play a role in healthcare reimbursements? What are the drawbacks and benefits?