Patient satisfaction should not influence how doctors are paid

Patient satisfaction should not influence how doctors are paidMedicare is thinking of using patient satisfaction scores in part to determine bonuses to hospitals.

According to Kaiser Health News,

… patient gripes soon will affect how much hospitals get paid by Medicare.

The Centers for Medicare & Medicaid Services is finalizing details for the new reimbursement method, required by last year’s health care law. Consumer advocates say tying patient opinions to payments will result in better care. But many hospital officials are wary, arguing the scores don’t necessarily reflect the quality of the care and are influenced by factors beyond their control.

This is seriously misguided policy.

I wrote last year, in a USA Today op-ed, that patient satisfaction scores should never influence how doctors are paid:

Satisfaction scores give patients a needed voice to express their concerns, which can help medical professionals improve their patient relations. But it’s a mistake to use patient satisfaction as a doctor’s financial carrot.

After all, a totally happy patient isn’t necessarily one who has received the best medical care.

Indeed, as progressive columnist Paul Krugman wrote in the New York Times,

medical care, after all, is an area in which crucial decisions — life and death decisions — must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge. Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.

That’s why placing such an emphasis on patient satisfaction can endanger the almost “sacred” relationship that Krugman mentions.  Although we’re treating patients more like customers these days,  in medicine, the customer isn’t always right.  A financial motive to increase patient satisfaction scores may lead some to order a test or prescribe a drug that goes against their better medical judgment, all to meet a certain patient expectation of the encounter.

Don’t get me wrong. It’s important that patients be given a way to provide constructive feedback to doctors. We need to hear about it when we fail, and be receptive to suggestions on how to improve.  Patient surveys are an essential, and necessary, tool.  But it should be mutually exclusive from money.

Because it’s important to realize that, sometimes, the best medical practice means not always giving patients what they want.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of, also on FacebookTwitter, and LinkedIn.

Comments are moderated before they are published. Please read the comment policy.

  • Rob Lindeman

    Agree, agree, and disagree (with Krugman: a “sacred” relationship? Come on! As my Brazilian families say “So Deus” (only (with) God))

  • paul

    because nothing will curb the medicare cost death spiral like incentivizing docs to placate their patients with more unnecessary tests and treatments.

  • Angela Caffaratti, MD

    Let the marketing machine start…

  • Muddy Waters

    Sooooo….how is this supposed to stop the exodus of physicians dropping Medicare/Medicaid? More regulations, less reimbursement, 100% liability. What intelligent person would ever sign up for this anymore? The federal government…winning! (duh)

  • inchoate but earnest

    “Patient surveys are an essential, and necessary, tool.  But it should be mutually exclusive from money.”

    You’re a noble spirit, Dr Pho. Would that all your colleagues were.

    No one is proposing to base all, or even most, or even much, of a physician’s compensation on patient satisfaction. You’re concerned about putting a paltry 1% of compensation at stake on patient satisfaction? You must not value your patients’ perceptions, attitudes, judgments much – if at all.

    • J. B.Lake

      It is presumptuous to conclude that Dr. Pho ” must not value…patient’s perceptions, attitudes and judgements”. Consider difficult decisions with chronic pain patients, or others where, for example, refusing an unnecessary MRI based on clinical findings and other studies leads to negative pt. satisfaction and negative online review, then multiply this by X number of patients and despite compassionate, quality care your provide profile is impacted. HTese measures are importantbut in the right context and used to improve effectiveness and outcomes.

  • soloFP

    Often satisfied patients will not fill out the surveys. The least satisfied and disgruntled patients are most likely to report on their experiences. I do find some of the websites interesting in that patinets gave low ratings for doctors failing to explain how to take the meds and for hospitals with dirty rooms.

  • Tim Richardson

    Satisfaction can be used to determine payment using a formula. Assign each component of “quality” a weight.

    Satisfaction can be weighted to reflect the ambivalence with which the healthcare system currently views satisfaction: 15%.

    Process measures (eg: routine assessment of HgA1c for diabetics) are becoming less “in vogue” so they will get a similar, “light” weight: 20%.

    Outcomes are again rising (re-hospitalizations within 30 days), due to better risk-adjustment tools, so let’s give them greater weight: 45%.

    Structure is a poor determinant of quality (minor surgeries in family practices) so structure will also contribute little to the overall quality score: 15%.

    Access will be guaranteed for most Americans by 2014 so let’s not waste too much effort measuring a given variable: 5%.

    Measure each component and multiply by specialty and geographic-specific factors based on expenses (we already have this data from the Resource Based Relative Value System so let’s use it).

    The result could be tweaked annually with survey data on costs and updates to the weighting system based on the supply of and the need for the various specialties. Perhaps the Independent Payment Advisory Board could make these recommendations.


  • ninguem

    Tap a beer keg in the office and lay out bowls of Percocets like they’re beer nuts.

    Great satisfaction scores.

  • Health as a Human Right

    I whole heartedly agree. Patient satisfaction should not interact with financial incentives at any level. As Krugman also says – Patients are Not Consumers. ( Though patient satisfaction must be part of the equation in delivering good care, not everything a doctor does should be based on whether they get paid for it or not. Doctors should use their professional judgment to give the best care they can. The ultimate goal is health not report cards that influence payment. We shouldn’t have to incentivize a good bed side manner, listening to patients, or responsibly involving patients in their own care.

    • horseshrink

      I’ll be darned, Dr. Krugman and I actually agree on something!

      I think, though, that we come at it from different directions. I believe (key word, “believe”) that market dynamics would usefully be re-introduced into the physician / patient relationship (currently insulated out of the interaction by third party payers.) Done correctly, I think this could contain/lower healthcare cost. With this, I believe we should move to catastrophic insurance coverage only. The government’s role should be limited to public health clinics for those in poverty, and wellness promotion/disease prevention services.

  • Edward Leigh, MA

    Dear Dr. Pho: Always enjoy your thought-provoking writings. With all due respect, I have read research that states excellent patient satisfaction and excellent clinical care are connected. I believe weak communication skills on the part of the clinician contributes to poor care. I teach clinicians how to “manage patient perceptions.” For example, patients often give low satisfaction scores on the question, “How well was your pain controlled.” Clinicians need to explain to patients that even with best meds they may still have some residual pain. Patients give low scores because they still feel some pain. We need to explain to patients what “controlled pain” really means. Dr. Pho, keep up the great work!

  • KP doc

    Patient satisfaction can be a part of how physicians get paid when/if the patient do the paying. Until then, it’s a serious mistake. I totally agree with Kevin Pho.

  • Edward Leigh, MA

    Now that reimbursement will be tied into patient satisfaction scores — will that force clinicians to take a closer look at their interactions with patients? The biggest concern I have is that some clinicians see communication skills (a big part of patient satisfaction surveys) as touchy-feely and non-significant. Communication skills is much more than “bedside manner;” it is about carefully listening to patients WITHOUT quickly interrupting. It is also avoiding asking, “Do you understand?” — a question that doesn’t accurately assess whether a patient actually understands. (Many patients automatically say they understand when do not — this happens for a variety of reasons, such as pleasing the clinician.) The “teach back” method is a great tool to use to determine if a patient actually understands. I submit my comments with all due respect to people who have differing opinions.

  • IVF-MD

    Aren’t surveys a bad reflection of patient satisfaction? A patient’s willingness to continue to see you and to refer their friends to see you is a much better reflection. It is more natural and does not require artificial data manufacture.

    My compensation is almost entirely based on patient satisfaction. They come to me to solve their fertility problem and keep their experience as pleasant and stress-free as I can. If I succeed in satisfying them, they tell their friends and also come back themselves when ready for their second child. If I don’t satisfy them, then they would leave and say bad stuff about me.

    In my opinion, my job satisfaction, in a scenario where every bit of effort I make can make a difference, is much higher than that of my colleagues for whom their compensation is guaranteed and secure with little effect, neither positive nor negative regardless of their effort.

    There are a lot of good healthy incentives that arise when patients speak their minds by choosing where their healthcare dollars go, well at least in comparison to fields where compensation is based on how well the doctor plays the CPT coding game.

    • pcp

      IVF, what you’ve described is professionalism, a completely irrelevant quality in the service industry of corporate medicine that we’re creating.

      • IVF-MD

        I agree with you, pcp. I would question that corporate medicine is what WE are creating. It’s what THEY are creating (meaning the corporations). WE, the working people want freedom to choose our own options. Agreed?

        • pcp

          I would include the AMA and all the primary care medical societies in the WE. They are fully committed to corporate medicine.

  • Paul Dorio

    “After all, a totally happy patient isn’t necessarily one who has received the best medical care.”

    Lol! As if a gorgeous entry way and polished brass railings, immaculate private rooms, gift shop, restaurants, and gentle piped music in the halls makes a difference when one needs high-level medical care! Yes, those things might help with mental healing, but how many times have we heard or read people’s impressions that comment on similar aesthetics?

    It’s a little more difficult for patients to say: “Man, my oncologist really knows the difference between doxorubicin and avastin!” or “gosh I had a very skilled interventional radiologist place my port the other day!”

  • horseshrink

    As a psychiatrist, if every patient is happy with me, I’m committing malpractice somewhere.

    • IVF-MD

      Would you elaborate on this? I’m curious to learn more. Thank you.

      • horseshrink

        This first came to mind while doing correctional work, where it’s most obvious. Inmates frequently confuse wants and needs, and I was often an obstacle to their various nontherapeutic objectives.

        More generally, if I give all patients everything “wanted” (to make them “happy” so they will come back to see me again), I am likely at some point merely to be enabling a way of living that was broken enough to prompt an appointment with me in the first place. Examples of this seen too often in the community = Dr. Feelgoods with easy Rx pads … or docs who advocate liberally for disability benefits at patients’ behests.

        Additionally, when it comes to caring for those with serious mental illnesses, anosognosia is a frequent complication. A man with 30 prior hospitalizations who is busy yelling at voices and cameras in the ceiling will insist he’s well … and is not the least bit happy with me or grateful when court-compelled hospitalization or medications are used over his objections … even after he feels better.

  • Doug Capra

    I think it’s important to analyze patient satisfaction. Granted, some, probably most, satisfaction issues shouldn’t have anything to do with salary. But how about these:
    — Communication skills.
    — Never returning calls or explaining things.
    — Lack of empathy
    — Outright rudeness
    — Not respecting patient dignity
    There may be some areas, some bottom lines, where the doctor either needs more training and mentoring or
    faces other consequences.
    What I’m saying is that “patient satisfaction” can be spread out along a continuum from less important issues to critical ones.

  • carol

    I express my satisfaction or dissatisfaction with my feet. I had a terrible experience at a hospital I used to trust and use even when I had to travel 1 1/2 hours on Amtrak to get there. When I was there a while back the nurse anaesthetist was nasty and abusive. They changed anaesthetists but this woman cane back into the room, continuing verbal abuse even with the doc there, who did not take control of his procedure room. I ended up crying when I was out out and awoke crying. I have had to go back there recently for a small procedure only after other avenues to get it done elsewhere proved difficult/fruitless.
    I willnot use the hospital or doc again. I tried to get the hospital to respond to the complaints and problem (other nurses told me this particular anaesthetist was a problem for the unit). They did not. And as a result a doc lost a patient, the hospital, lost my business, but, more to the point they lost my goodwill. I do not recommend the doc or the hospital to anyone and say, as a result of my experience, they should run the other way.

    • IVF-MD

      Carol, good for you to stand up and be counted like that. Now, in a true free market, if enough people shared your disapproval of the bad treatment that they got there, then business for that hospital would dry up and they would either become extinct or be forced to improve their ways.

      However, in our current reality, it might be more an issue of contracts and managed care agreements. So perhaps all the patients are dissatisfied, but when it comes down to a decision of going back to that hospital for free (nothing is really free. It’s either paid by your employer or on the backs of working tax victims) or going to somewhere more caring and having to pay, enough patients will choose the free offer. This way, bad providers will continue to exist and not be motivated to change their ways. This is but one of the reasons why patients continue to see doctors that they are dissatisfied with. Some day, when we wake up and get back to a free market model, things will improve.

      • carol

        I am lucky in that I can choose to go anywhere and see any doc. For sure it is not free, it is essentially socialism. I pay my premiums; and you pay yours. When I am sick, your premiums help to cover my costs and vice-versa. (in house at least as per company). Our taxes cover those who cannot afford or get insurance.
        (Before I could qualify for s.s.disability I had to go on public assist. My care was “free”. I saw residents and then attendings when necessary. I had no choice when the care was bad (but it was usually pretty decent) Once I found out I actually had BC/BS (long story) I tried to make app’t with resident who was now in private practice. Regardless of my insurance (which was excellent) he would not see me without money upfront. A good doc lost my good will, and a patient, due to pure and simple greed.
        I just had a conversation with someone who told me about her doc. She says he does not communicate well and hurts her. Why do you keep going back? I asked, “Well,” she said “I am not going to go back anymore.” but this was after her 4th visit with this guy who kept doing things she said he did without fully discussing them with her. Sometimes he tells her after the fact. She also tells me she has told him more than once she cannot hear him and does not ‘get’ everything he says.
        Now I do not know what the real story is but a doc who continues to treat a patient who has expressed dissatisfaction is asking for trouble. A patient who goes back, and back, is silly (at the least).
        Patient satisfaction is important but there are too many variables to make it a structural pay issue.
        ( )

  • bekool

    Would you pay a roofer and recommend him if he did a lousy job ? Would you complain to management if you received a undercooked meal ? Would you not complain if your hotel room was dirty ? Not holding doctors and the health care / insurance industry accountable to their customers being us, caused the problems we have .

    • horseshrink

      I’d be pleased as punch if “the problems we have” were simply and solely a matter of “not holding doctors and the health care / insurance industry accountable to their customers.”

      • carol

        Part of the increasedcosts for malpractice, etc is because themedical community and state will not sanction the recidivist docs who commit malpractice. Public Citizen a while back found that 15% of docs commit 85% of the malpractice. Le the docs come forward about theur colleagues who commit malprctice and patient satisfaction will automatically go up because you have weeded out some ofthe bad ones (That is not ignore the issue of poor communication, etc on the side of both patient and doc.

        • Tim Richardson

          No, “weeding out the bad ones” not fair to docs who practice in high risk specialties like ob-gyn and neurosurgery. A “bad” doc is not necessarily the one who is sued 4-5 times in her career – she may be practicing on patients who tend to have bad outcomes.

          This “patient satisfaction” argument is inherently different from a “patient outcomes” argument because satisfaction is almost wholly derived from the patients’ perception while outcomes are pre-determined and independent of the patients’ perception.

          Outcomes can be risk-adjusted using predictive factors known to affect the outcome like age, co-morbidities and psycho-social factors.

          To my knowledge, we can’t risk-adjust patient satisfaction scores.

          But, on this point I disagree with Dr. Pho, we need to use money to incentivize people in the system to make patients happy and, at the same time, give them good medical care.

  • Crissie Reichert

    patient surveys do not reflect the quality of care – that is determined by their outcomes.  Patient satisfaction surveys (such as NCR Picker) hone in on how the patient was treated by their care team.  Did the nurses pay attention to your needs, were your procedures explained in detail to you, was your pain effectively managed, did your physician explain to you what medications you were being put on and why?  Yes, many patients are more concerned about when their next meal is coming, but the days where medicine is practiced “to” the patient instead of “with” them is in the past.  I applaud hospitals who take this seriously, and if incentivizing them to do so will help, then all the better. 

Most Popular