How paying doctors for patient satisfaction is racist

Part two of the three-part series, Let’s Pay Popular People More!

Take a moment to ask yourself whether any of these categories describe you or someone you love:

  • Never had cancer
  • Psychologically distressed
  • No regular health care provider
  • No health insurance
  • Lack confidence in self care
  • Avoid doctors
  • Minority race

If any of these terms describes you or a loved one, then you are statistically more likely to give a doctor a lower client satisfaction score. When a doctor will earn less by treating you than someone else, how long do you think it will be before you start having a hard time finding a primary care appointment?

The first article in the “Patients Rating Doctors: Let’s Pay Popular People More” series discussed how paying doctors on the basis of client satisfaction surveys may actually undermine the care of our most vulnerable patients, as well as entire systems that struggle to address complex issues.

You might have been thinking that this issue doesn’t really affect you personally, other than on some vague, population-based health level. This list should make it clear that it may.

From a health disparities perspective, the most disturbing item on this list is race. Bias and racism (of all types) in medical care have been long recognized. They occur at almost every level and have been extensively studied to try to diminish the impact on population health.

Health disparities exist not just because of lifelong socioeconomic and environmental disparities, but also because of bias in health care. Focused efforts to address issues of racism among providers have measurably improved survival.

Government payouts based on client satisfaction surveys would do the opposite.

Studies show that patients rate same- and majority-race providers higher than minority providers. Patients will state up front that they believe they get better care from a provider of the same race. What’s more, a doctor’s race influences client satisfaction much more than gender or religion. These differences are so pronounced that there has even been a call to use different questions for African American patients and to throw out the “extreme” results from people with “less educational attainment.”

Even leaving out issues of racism, you can just imagine a doctor’s perspective: Who wants to take care of a patient who is statistically likely to rate you poorly when your payment for services is based on that same rating? Would cutting payments to doctors who are racially insensitive make them more sensitive and willing to take on more minority patients? Or is it likely to make it even harder for minority patients to get health care?

So why is no one discussing this obvious flaw in satisfaction-based payment?

No one wants to step forward and criticize client satisfaction surveys. Doing so comes across as being anti-patient. But surveys are one thing, and payment is another thing altogether. Paying doctors on the basis of popularity would create, for the first time in any profession, a system that financially rewards racism and bias just as we are beginning to make some small, but significant changes to the huge racial disparities in health care.

And there is another, equally important problem with paying doctors based on popularity. Racism and bias work both ways. There’s provider-against-patient bias, but there’s also a less talked about patient-against-provider bias. According to both studies and anecdotes, basing payment on client satisfaction surveys can discriminate against minority physicians.

Patient satisfaction is deeply associated with provider race in a complex way. Being the same race as the patient, whatever it is, results in higher satisfaction ratings, which puts minority providers practicing in majority environments (such as academic medical centers) at a huge financial disadvantage.

I discovered in medical school that patient bias against providers is not just a statistical phenomenon, but a painful reality. A medical school classmate — brilliant, kind, and gentle — would be sent, like all of us, into a patient’s room to do a “work-up.” But her experience was often very different than mine because she is African American, and I am white. For her, the conversation with a patient often began with being forced to explain that no, she wasn’t there to empty the trash.

Not once did I ever have to explain that I wasn’t supposed to take out the trash.

And it continues on past medical school. Both my minority physician friends in private practice and even some of my neighbors and acquaintances will talk in veiled ways about how patients might not “warm up” to a certain — say, Asian-American — physician. This, we all know at some deep level, is code for a form of racism.

Should our government discriminate against minority doctors because of this bias? Almost no one feels comfortable discussing this. None of us really wants to think about patients being racist. But patients are, after all, us, and we, as a society, are biased in endless, too-numerous-to-count ways.

After all our struggles to get to some degree of equity in our health care and society, why would we start a government-run program with different rates of doctor-payment based purely on popularity?

As our government takes steps to use client satisfaction surveys as a basis for physician payment, we are, as a society, moving toward using our tax dollars to deliberately enshrine and reward bias.

Jan Gurley writes for Reporting on Health, a USC Annenberg School of Journalism online community for journalists and thinkers. Her blog explores the practice of medicine on the margins of society and what we can learn from it. You can see more of her posts here.

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  • Health blog

    This rings true. Still the big reason not to pay based on patient satisfaction is to avoid adding one more incentive (besides it’s easy and fast) to just give patients what they expect and get them on their way quickly. “Here is your antibiotic for your URI.” Happy patient, good satisfaction, short visit more profitable, more profits from happy patient satisfaction survey vs. Longer discussion of viral illnesses, possible dissatisfied patient, poor survey grade –. longer less profitable visit and add to the pain less pay because of dissatisfied patient. It’s harder to do the right thing, don’t put more financial risk into the formula.

  • Matt

    This post just illustrates how ridiculous the whole physician compensation scheme has gotten. On the one hand, every professional is paid in large part as a result of client satisfaction. On the other, it’s not through some crazy survey scheme.

  • solo fp

    I know a few popular docs in my area who will get good ratings. They give out narcs and benzos to anyone who wants them. Work notes are written all day and FMLA is routine. They have happy and satisfied patients, along as the patients get what they want for their $20. Longer visits will not make patients happier, but getting pills for whatever they want will mean great patient satisfaction but not necessarily improvement in quality of care.

  • pcp

    The only valid indicator of patient satisfaction is whether or not the patient elects to stay in the doctor’s practice.

  • GD

    I think the more interesting debate for those who don’t agree with tying reimbursement to patient satisfaction is what would be a better alternative? Or, should a physician simply not have to concern him or herself with whether or not a patient is satisfied or unsatisfied with the care they received? The fact is, there’s currently a retail revolution taking place in healthcare. It’s primarily been created because of the shift in payment responsibility to the patient (they now have a seat at the table), the incredible access to information we all have and the social networking phenomena. I can’t be stopped. And, if that’s the case, in the end, patient satisfaction will impact reimbursement – not in the form of reduced payer payments because of poor survey scores, but rather, there will simply be fewer patients waiting in line to see a provider that delivers subpar customer service (note that the primary driver of a satisfied patient is NOT clinical excellence – it’s a great customer service experience).
    An example of this playing out: Gen X & Y patients are more likely to base their decision of where they go for care on a friends recommendation than they are on a physician recommendation. The rules have changed. Those physicians that don’t choose to recognize that good non-clinical customer service is a critical component to patient satisfaction will be slowly left behind and their practices will be increasingly filled with individuals that are in the practice not because they choose to, but rather because, for some reason, they simply don’t have the ability to switch. And that’s a recipe for disaster – unengaged patients, poorer clinical outcome, etc.

    Something to consider, is this debate similar to linking teachers pay with student test scores? Just a thought.

    • MIS Prof

      Good point. It gets worse … linking pay to student satisfaction surveys … oops, I mean student evals. Texas A&M is doing this right now. We faculty have long known how problematic student eval surveys are as a measure of good teaching, especially if they are the only measure. I’ve personally known a large number of faculty (in three states) play games to improve student evals, including grade inflation or adjusting a course to make it less rigorous. (My evals are good and I’ve earned tenure three times, so I don’t have a personal axe to grind.)

      I can’t imagine applying that in a health care setting.

      If there is a shortage of doctors or specialists (say PCPs) or an insurance restriction (say, Medicare), even returning patients are not a good measure.

      That said, it’s not a bad thing to check patient satisfaction with the doctor or with the office staff. Feedback did help me improve my teaching over the years (or at least warned me about what annoyed students).

      Such surveys shouldn’t be used alone and shouldn’t be used in determining pay, though.

  • Sister Margaret

    Wow, this article tops it–a case being made to discredit the importance of “physician satisfaction” opinions of patients! First, as a nurse, I have witnessed a greater patient apathy, lack of confidence in self-care (lack of responsibility for efforts to change life style or embrace healthy behaviors) and limited patient compliance/ability to collaborate with physicians in their own treatment–of less education/lower income patients–and yes, many of them are patients of color. Many of the same low income/uneducated patients may still believe in the stereotype that a black doctor is really “maintenance” staff…. but that same individual may confuse a male nurse with a doctor–why? Because most nurses still are female!
    My husband was referred to a black surgeon for removal of skin cancer (the first black surgeon he/we have ever known) and his response was, ‘wow, this gal was great–she had a great story too, told me of how her dad was (began as enlisted) in the military, they traveled all over the world, she spoke Japanese because her dad was stationed in Japan during her “formative years”…. and so on. Let’s look at the factors creating stereotypes… and the factors “undoing” the stereotypes.

    • pj

      Ummm.. ok.. So what do you suggest????

      It is unfortunate that you seem critical of an article on an issue that goes unmentioned far too much!

      Thanks to all the other posters for excellent points, especially “Paul.” I quote him -

      “there are times when patient satisfaction and appropriate care are at odds. and in those cases delivery of appropriate care should always trump satisfaction.”

      Amen my friend.

  • Ken

    Excellent points. Therefore a black doctor should get great reviews in a black neighborhood. This should lead more black doctors to serve their own communities.

  • NeoMD

    This is very thought provoking. Throughout my career it has been common for me to hear the parents of my neonatal patients complain that the doctor never talks to them- despite the fact that I am a strong advocate for family centered care, spend a long time patiently explaining things to them and always introduce myself as Doctor. I am a youthful appearing middle aged white female. And it does seem to correlate somewhat with their level of education. Even when I am wearing my name tag, call myself Doctor they still call me “missus” !!!!

  • arg

    If you know what you’re doing, there is an easy, “non-racist” solution to the potential problem of incentivizing physicians to avoid populations that predictably differ in their survey responses. It’s called “stratification.” What you do is you give each physician (or practice, hospital, etc) a separate rating for each patient population that you’re worried about. Then patients can see how each provider does in each category, which in addition to leveling the playing field, has the added benefit of showing how a provider does for “patients like me.” As a third benefit, this approach prominently displays internal differences (or “disparities”) in the performance a provider gives to each subpopulation, rather than sweeping them under the rug–and allows comparison of these differences across providers. Some providers will have greater internal disparities than others, which may highlight opportunities for provider education.

    I hope this doesn’t upset anybody’s plans to make a career out of calling reports “racist.” While patient/provider race issues are indeed important, reporting isn’t the problem here. In fact, failure to measure and intelligently report performance is likely to prevent anything from improving.

  • paul

    ugh. as it was mentioned in the article, any time we start griping about this topic some uninformed segment of the population starts accusing us of being anti-patient. which prompts me to always start these discussions by saying- i am in no way suggesting that patient satisfaction is not important. of course we want our patients to be happy and satisfied. in an ideal world we have happy, satisfied patients who also receive appropriate care and have a good outcome.

    but there are times when patient satisfaction and appropriate care are at odds. and in those cases delivery of appropriate care should always trump satisfaction. antibiotics for the common cold. percocet for acute on chronic percocetopenia. advanced imaging for cases with robust evidence showing the test to be unnecessary.

    and let’s be clear about something. the people in support of giving these surveys a whole new level of power over us are not interested in patient satisfaction. the business people running hospitals who swear by these things ultimately want high numbers because it translates into more money in their minds, out of the belief that health care follows the traditional business model. politicians, if they are pushing for this, are not doing so to make patients more satisfied, but because UNsatisfied patients will give them a good excuse to withold payment and save some money.

    of course, i find it doubtful that we will save money by taking a bunch of providers and patients, having them continue to be unaccountable for the cost of unnecessary tests and treatment, and then financially incentivizing the providers to make their patients happy above all else in a society where more testing = better care.

    what really concerns me about all this is how deep press-ganey and the like have their claws into the health care system. will they be conducting the surveys that cms will then use to determine reimbursement? will our tax dollars go to press-ganey to pay for this? i’m sure that would be like the holy grail to them. they’ve already somehow managed to get my professional board to “loosely” require submission of satisfaction scores as part of board certification, and i would doubt that my field is the only one with such a requirement.

    in the end, how much our behavior changes as a result of something like this will depend on the extent to which our pay is affected by satisfaction scores… which will probably ultimately be a small enough extent that many/most of us will still try to continue to do the right thing, but have yet another thing to complain about in the practice of american medicine…

    well that was longwinded of me but this is probably the second most annoying thing to me about practicing medicine in this country.

  • Penny

    I find that in my own city of mainly white people the only doctors taking new patients are of another race or colour, and usually have less than 2 years of experience. While I could switch from a doctor of my own race and colour who has more experience, I would tolerate a lot of incompetence on his part before switching.

    I think all patients are far more comfortable with doctors of their own race and colour, and if they are forced to choose one of another because there are none available in their own, misunderstandings may be felt from the start.

    No one likes to feel different, as can be proven when you visit any big organization. In those places, in spite of the fact that governments order us all to be tolerant, each group tends to sit at its own table and even speak its own language, or if there is only one table, one end will traditionally be chosen by people of a certain race and the other by people of another.

    I remember one time when a lady came to me in a lunch room and said she felt uncomfortable because she was the only Asian in the lunch room that day. What? Up until then it never even dawned on me that she was Asian because she had the type of look that would’ve meshed in with just about any colour! But that just goes to show how a person’s own self-image can create the belief that others may not like them.

    Clearly no one likes to feel different, not necessarily because they are biased against certain colours or races, but because of their own self-consciousness and awareness of differences in culture and understanding.

    It’s degrading enough being stripped down in front of a doctor of your own race and colour let alone one who might see your horrendously deathly white skin as being even more ugly than you yourself think it is, compared to his own nicer coloured skin. When a person feels self-conscious, their own images of themselves become highly magnified, especially the negative ones. Even if they are aware of that, it’s hard to think differently.

    With regard to race, my own parents fought constantly before divorcing. Eighty percent of their arguments were as a result of their huge differences in understanding due to the fact that they were raised in entirely different countries with very different traditions and expectations. For that reason I never wanted to date a person from another race, even though I was often strongly attracted to people of races other than my own.

    So yes, I do feel it’s true that doctors of another race or colour may receive lower ratings due to this misunderstanding as well as a patients’ own images of themselves which may change when confronted with another colour.

  • Penny

    Firstly, the trouble is that most ratings aren’t broken down enough, so they do much to help a doctor improve in the areas he is weak. Basically they seem to be little more than popularity contests. Also, after the third day of major surgery a patient in extreme pain will be more inclined to give a negative response compared to what he might give a year later.

    Secondly, how do you rate a doctor who is always at least an hour late for his appointments but gives each patient the full time he needs? Do you rate him a 1 for punctuality which makes him look like a disorganized doctor when he’s actually the best that can be found on the planet in other areas? There’s no better doctor in my eyes, than one who “doesn’t” treat patients like a time slot.

    Unfortunately, even if patients make comments that are highly flattering to the doctor after giving him a 1 rating, those comments do nothing to raise his rating when they should really alter his total tremendously.

    Bottom line is that if doctors were to be chosen for quick selection for a prize based on ratings totals, those in charge wouldn’t even bother to read the comments of those with ratings that had been lowered due to punctuality, so the best doctors would be selected based on only the top scores. Furthermore, what’s to stop a doctor from getting all of his friends to post high ratings for him when most of these ratings are actually given by people with anonymous or false names? How fair is that?

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