The chief medical officer for Press Ganey Associates, Dr. Thomas Lee, recently posted a blog article in the New England Journal of Medicine, “The Pain That Results From Pain Management.” It is no surprise that Dr. Lee takes a stand in defense of patient satisfaction surveys. His company is one of the leading companies in the medical survey industry. With the emphasis placed on the opioid epidemic in our country, Press Ganey, and other companies are under scrutiny. Are their surveys causing doctors to prescribe more narcotics?
Dr. Lee states that there are no financial incentives for doctors to prescribe pain medications, and technically there are not, not directly. This sweeps under the rug the reality that a clinician’s performance and compensation is based on a number of factors, ranging from work RVUs (relative value units) to, yes, patient satisfaction scores. Patient satisfaction scores do tend to be lower for health care providers who do not prescribe what patients want.
Dr. Lee goes on to say, “I don’t dispute that simply knowing that pain control is being measured can change the way physicians practice — and that this awareness can lead to better care for some patients and worse care in others.”
Let’s talk about that “worse care.”
A 2012 study in Archives of Internal Medicine gives a taste of what patient satisfaction surveys can do and not in a good way. Data from approximately 52,000 adults was assessed from 2000 to 2007 via the Medical Expenditure Panel Survey. A 26 percent increase in mortality rates was observed in those who were most satisfied. Those with the highest satisfaction scores also had 9 percent higher medical expenses, spent 9 percent more on prescription medication, and were 12 percent more likely to be admitted as inpatients. Giving people what they wanted actually hurt them.
The problem is that what matters to patients and doctors does not always align. Someone may push for unnecessary testing because they read it on Google or Dr. Oz recommended it on his show. Someone may push for medications that are not medically indicated, i.e. antibiotics for viral infections. Someone may push for narcotics but refuse other pain control options offered by their providers. People are not always receptive to “no,” and some will threaten doctors with a low score.
It takes time for doctors to educate their patients about their care, time to explain why their requests are not medically necessary, or why other options may be more appropriate. Sadly, what doctors lack most is time. What happens? The next person on the office schedule gets upset when appointments run late. Left in the waiting room, a patient could already be down-rating their own patient satisfaction score.
When it comes to care received in the hospital, things get more complicated. Staying at a facility for hours or overnight adds additional services to the mix. Someone could receive appropriate, quality medical care but complain that food was delivered to their room late, that there were not enough meal options, that roommates snored too loudly, that the room was too hot or cold (while their roommate says the exact opposite), or that there were not enough channels on the television. Hospitals are not hotels or spas, and their top focus should not be on non-medical amenities. Still, it is part of the patient experience and patients will and do report on it.
Don’t get me wrong. I see patient satisfaction surveys as a highly valuable tool. Of course, they are! There is always room for growth and improvement. The only way to learn where our faults are is to ask.
Health care needs to be compassionate while maintaining a quality, evidence-based focus that will most benefit the patient. That means listening to patients. That means prescribing when appropriate. If that is not happening, we need to dig deep and find out how to change for the better. Everyone — doctors, and patients alike — wants the care experience to be a positive one, but both need to understand that some things are out of their control. Pain cannot always be reduced to zero, I am afraid.
I agree with Dr. Lee that patient satisfaction surveys have their place. I agree they can deliver valuable information that can impact positive change. However, as they stand now, they also promote false expectations. They hand the definition of “quality care” to the patients and undervalue the medical judgment of clinicians. There have been negative consequences as a result. To imply that patient satisfaction surveys have not contributed in some way to the opioid epidemic is to shamelessly pass the buck.
In his blog post, Dr. Lee asserts that doctors are simply uncomfortable being judged and that is why these surveys have been a matter of contention. Then again, he acknowledges “we need more wisdom about what to do with the data.” I say, we ought to be careful when choosing what data to collect in the first place. We should collect data that has immediate relevance for medical care. We should not have patients judging whether a particular medical treatment is appropriate when clinicians are the ones trained with that knowledge. We have to be able to look past a subjective score and look into the clinical context of a situation to see if it meets standards of care. We also need to discontinue any financial incentives linked to patient satisfaction surveys. These surveys should impact on care quality, not wallets.
No one wants to take responsibility for the opioid crisis. The truth? Multiple factors led to the current state of affairs. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) emphasized pain scales with the implication that patients ought to be pain-free, an unrealistic expectation. Patient satisfaction surveys inadvertently decreased the importance of clinical judgment in the eyes of the public. The federal government also played a part by financially incentivizing hospitals based on patient satisfaction scores. Some doctors began to overprescribe medications due to these external pressures.
There is no one person or group to blame. Just like every doctor is not responsible for the opioid epidemic, not all patients are drug seeking. Far from it. Though policies by JCAHO and other agencies miscalculated the effect they would have in increasing narcotic use; their intention was for a better care experience. We need to shift from blaming to problem-solving. Only when we come together can we turn the tide of addiction. Changing the approach to patient satisfaction surveys would be a good start.
Tanya Feke is founder, Diagnosis Life.
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