Emergency department visits tend to be urgent and unplanned, and
inpatient visits are usually necessitated by serious injuries or
illnesses, with the exception of women who are admitted for
childbirth. Among both emergency department patients and
inpatients, hospital satisfaction ratings vary significantly
according to the patient's payor type -- namely, Medicare patients,
Medicaid patients, those with HMOs or PPOs, those using other
commercial insurance, and self-payors. But what about outpatient
services, where conditions are less likely to be life-threatening
and services are more likely to be elective?
The two types of outpatient services for which Gallup measures
patient satisfaction -- outpatient surgery and outpatient test and
treatment -- show different patterns of variation by payor class.
Outpatient surgery scores vary less by payor class than
either inpatient or emergency department ratings. Its more
consistent satisfaction across payor categories can be explained
largely by the overall high level of satisfaction with outpatient
surgery (it is the highest rated of the four areas Gallup
measures), its more elective nature (patients are more likely to be
having outpatient surgeries out of choice, rather than necessity),
and that outpatient surgery patients have greater freedom to select
their own facilities.
Satisfaction scores for outpatient test and treatment
show more variation by payor class. Average scores in four of the
six payor categories vary significantly from the mean satisfaction
score -- the most variation of any of the four areas.
One payor category -- self-paying patients -- gives
lower-than-average satisfaction ratings for both
outpatient surgery and outpatient test and treatment services.
Self-payors, who generally have no insurance and are paying their
own way, tend to be the lowest-income patients. Because
outpatient surgery procedures are usually planned ahead of time and
don't stem from life-threatening conditions, physicians and
hospitals can be more selective in the patients they accept. It
could be that self-pay patients are less likely than other patients
to be able to access outpatient surgery services, and are more
negatively influenced by high costs when they are evaluating their
experiences. They might also be more likely to forego the most
desirable treatments due to cost, and may therefore be less
satisfied with the overall effectiveness of the care they
received.
Self-pay patients are also least satisfied with outpatient test
and treatment services, an area in which Medicaid patients also
give below-average satisfaction scores. In fact, outpatient test
and treatment is the only area in which Medicaid patients, who also
tend to have lower incomes, have significantly lower-than-average
satisfaction. Conversely, as with emergency department
satisfaction, Medicare patients have higher-than-average
satisfaction with outpatient test and treatment. Medicare patients
are more likely to be frequent users of outpatient services; that
greater familiarity may breed increased patience and
confidence.
Bottom Line
Our analysis over the past few weeks of patient satisfaction by
payor class in four areas -- inpatient, emergency department,
outpatient surgery, and outpatient test and treatment -- has
revealed several key findings:
- With the exception of outpatient test and treatment, Medicaid
patients do not have lower-than-average levels of patient
satisfaction. It does not appear that this low-income group feels
discriminated against by the healthcare system overall.
- In general, patient satisfaction is highest among Medicare
patients and lowest among self-pay patients. Satisfaction ratings
by payor category vary most in the emergency department and
outpatient test and treatment.
- Outpatient surgery ratings vary least by payor class, but
satisfaction in this area still dips significantly below average
among self-pay patients.
The most consistent finding across service areas is the low
level of satisfaction among self-pay patients. Many people in this
group may be falling through the cracks -- unable to qualify for
Medicaid but unable to afford private health insurance. These
numbers are one more illustration of the need for repairs to the
healthcare safety net and broader access to insurance coverage.
It's also possible that these patients, many of whom are "no-pay"
patients (showing up for emergency treatment with no ability to
pay), are subtly viewed by the medical community as undesirable,
and could receive substandard service as a result.
Regardless of the reason, it appears that it doesn't pay to be
self-pay when it comes to the quality of healthcare services.
