Why linking patient satisfaction with dollars is misguided

I hope my patients are satisfied. This is everything. Improving the lives of people is why doctors do what they do. How much we help our patients is the metric. It’s the peg we hang our self-esteem on.

So yes, of course, patient satisfaction is really important.

But that doesn’t mean it’s a good idea to link it with dollars.

In fact, on a list of well-meaning but really dumb reform ideas, linking compensation of hospitals (or doctors) to patient satisfaction scores ranks near the top. Let me tell you why I think this way. It involves an important baddie—overtreatment.

Ever since reading this WSJ piece on the matter, I’ve thought about weighing in. Like so many good-intentioned ideas hatched in think tanks and cubicles, the problem is the unintended consequences seen in the real world.

A brief story: On my way out of the hospital the other day, I was called to the ER to see one of my patients. Due to privacy matters, I can’t tell specifics, but I can say that the problem related to his getting off “the program.” In this case, “off the program” refers to an utter failure to heed my warnings about over-indulging in substances that end in the sound “een.” (Say…caffeine and nicotine). Adding to this common digression was another shocker: non-adherence to Dr John’s well thought out less-is-more medical regimen. (Yes, I do occasionally prescribe medicine.)

So we had a nice chat about the problem at hand. Mustering all the strength I had left after a big day, I offered a few Mandrola-isms about avoiding intake of bad substances and adhering to a smartly prescribed regimen of evidence-based and inexpensive generic medicine. I made it clear that his health depended on him—not me.

Then I went out to tell the nurse and ER doctor, that not only could the patient be discharged, but that after our chat, his problem might be fixed.

I love visiting the ER. As medical blogs go, it offers a trove of potential topics. There was still time for a question.

I just had to ask the ER doc: “You have to do this a lot—talk to patients about the dangers of getting off the program?” He laughed. Looking around the ER that day, it was obvious the place was over-flowing with patients who had strayed far from “the program.” His partner, who overheard our conversation (all conversations in the ER are overheard by someone), added this: “Yeah, but now, with patient satisfaction scores, we have to be extremely careful not to make patients mad.” He was serious.

That got me thinking.

When finding fault with linking patient satisfaction scores with dollars, the knee-jerk reaction is to bring up the issue of opioid pain meds. So I did. “What if a patient isn’t happy with the amount or type of pain medicines you prescribe?” His answer came quickly: “That happens a lot, but in Kentucky, we are also on the hook if we give them too many.” (Ed note: Kentucky legislators recently passed a draconian bill limiting the prescription of opioids. It has had a chilling effect on the legitimate therapy of pain.)

Kevin O’Reilly recently wrote this comprehensive piece outlining the many problems with linking compensation to patient satisfaction scores. Earlier this year, Dr. Kevin Pho explained how patient satisfaction can kill.These are excellent discussions.

I’d add these two common occurrences from my world.

As Mr. O’Reilly points out: medical care is not the same as customer service. For instance, I believe strongly in the importance of explaining and then implementing TLC—therapeutic lifestyle changes. That gets dicey. Asking or expecting patients to take care of themselves risks converting them quickly to the ranks of dissatisfied. A much easier road for the doctor is to avoid the elephant in the room–and simply write the prescription, order the MRI or refer the patient on to another specialist. This behavior will only worsen if we dis-incentivize doctors to speak the truth. We already have too much care.

Another example: The patient is referred for a well-reimbursed procedure. One approach that a specialist can take is to do the procedure. It’s evidence-based and everyone is happy and satisfied. Another approach is to discuss and implement a trial period of lifestyle changes (or other conservative measures) that, if embraced, could lead to avoiding the procedure. The problem with the conservative approach is that it risks poor satisfaction scores. Many want the easy fix. Not doing in our system is far harder than doing.

Bigger care, more care, riskier care–these are the reasons why I oppose using satisfaction scores to pay hospitals and doctors.

I’ll close with this warning—from the real world of healthcare–to policy makers:

What you incent with dollars will happen.

John Mandrola is a cardiologist who blogs at Dr John M.

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