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National Patient Satisfaction Standards: A Leading -- or Misleading -- Edge?

National Patient Satisfaction Standards: A Leading -- or Misleading -- Edge?

by Robert Nielsen

This column is the first of a two-part series.

Gallup has decades of experience with helping hospitals improve their relationships with patients and employees -- we provide sophisticated information and business consulting to healthcare clients to help them become more competitive through quality patient care, productive work environments and expanded services. In that light, we have been asked by a number of hospital clients and others to give Gallup's position on the "national patient satisfaction standard" currently being proposed by Thomas Scully, Administrator for the Centers for Medicare and Medicaid Systems (CMS), an agency of the U.S. Department of Health and Human Services. As part of the Consumer Assessment of Health Plans (CAHPS) II program, hospitals are being directed by CMS to publicly report the satisfaction of their patients.

The stated purpose of the initiative is to provide consumers with a reliable metric of a hospital's quality from the patients' point of view. It's a sentiment that almost all can identify with, and certainly one that makes sense in light of the recent Gallup Poll surveys documenting declining confidence in the U.S. healthcare system. As the initiative currently stands, however, it's difficult to see how that outcome will be realized; rather than benefiting patients, the main effect could be to widen the gap between hospitals with greater and lesser resources.

As we examine the issue, we find that there are two extremely important questions to be dealt with:

  1. Will a standardized hospital patient-satisfaction metric made available to the general consumer actually improve U.S. healthcare services?
  2. If so, what is the best way to conduct the survey and to disseminate the results?

This column addresses the first question; the second question will be addressed next week.

Over the past few years, a number of attempts have been made on a state-by-state basis to develop a standard for publicly reported patient satisfaction scores. Efforts in Massachusetts and California are the most notable in this process. A 1998 initiative undertaken by the Picker Institute in Massachusetts was a significant failure with regard to both its methodology and execution; shortly thereafter, Picker was forced to declare bankruptcy. National Research Corporation (NRC) of Lincoln, Neb., a publicly traded healthcare market research company, acquired Picker, and the same questionnaire and methodology were adopted in 2000 by state healthcare agencies in California.

The California program, called PEP-C (Patients' Evaluation of Performance), is voluntary, with the stated purpose that it "…establishes a periodic public report on hospital performance, and gives all those concerned with the health care system valuable insights into the care provided in the state's hospitals" (italics added). The published results of the first PEP-C survey, conducted in 2000 and reported on in 2001, state, "The PEP-C survey is not a guide to "good" and "bad" hospitals. The survey did not ask for technical evaluations … such as how well a doctor performed surgery or whether correct medications and treatments were prescribed at the right time. The survey did not provide any indication how successful the care was …"

And yet, the 113 participating hospitals in 2001 (out of 400-plus eligible) were rated as one-, two- or three- "star" facilities. If PEP-C is not a guide to good and bad hospitals, how is one to interpret the difference between a one-star rating and a three-star rating? Obviously, the stated intention of the initiative is at odds with its measurement system.

How, then, is such a survey likely to be used? Blue Cross/Blue Shield (BC/BS) of California has found a way. BC/BS has mandated that hospitals that don't participate in the PEP-C survey could lose their preferred status as part of the BC/BS network. Losing that status would mean patients would have to come up with the higher co-pay for non-network hospitals. In a competitive market, that could be suicide for the non-network hospital. BC/BS has also stated that in the future, a marginal PEP-C report could also cause a hospital to lose its preferred network status. Such a move would lower costs for BC/BS, but hardly help struggling hospitals improve their services.

On a broader scale, one could speculate that CMS views mandated patient satisfaction surveys as a similar cost-cutting measure. Recent reports have stated that Medicare rolls will double within a generation. If CMS could reduce Medicare costs by 10% to 15% just by cutting reimbursement to hospitals with weaker ratings on the national survey, is that alone reason enough for them to mandate the process? It seems unlikely that CMS would increase reimbursement to those hospitals that do well on the survey.

If the failed public assessment of hospital patient satisfaction by Picker in Massachusetts or the current patient surveys being conducted by NRC/Picker in California are an indication of what's to come, we are very concerned that the mandate from CMS holds no upside for American hospitals and will provide misleading information to consumers using a mechanism fraught with bad science.

Finding accurate ways to measure patient satisfaction is obviously a critical goal for the healthcare industry and the American public in general. But it has to be done for the right reason -- and cutting costs without seeking ways to improve underperforming hospitals is not it.

Next week-- Bad science: How flawed methodology may doom CMS' current push for standard satisfaction measures, and recommendations for how such an initiative should be carried out.


Gallup https://news.gallup.com/poll/6736/National-Patient-Satisfaction-Standards-Leading-Misleading-Edge.aspx
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