The dark side of patient satisfaction scores

The Pediatric Insider

© 2014 Roy Benaroch, MD

We’re living in a world or ratings. Books get rated on Amazon*, dry cleaners get rated on Yelp. Doctors are getting rated, too—not only on web sites, but also in ways that end up dictating how much money we can make, or whether we can keep our ability to work in a hospital. Is this a good way to improve medical care or medical outcomes? Is it even fair?

We already know that ratings don’t reflect good medical care. In fact, patients who rate their doctors the best have shorter lifespans. They get more tests, more scans, more antibiotics—which may make them happier, but also makes them sicker.

You do not want a doctor who does what he thinks is going to make you post a positive review. You want a doctor who listens carefully and helps you make the best medical decision. Even if that means you don’t get an antibiotic.

 

But there may be an even worse, more odious problem being caused by the reliance on “ratings” to determine income. As Daniela Drake has written, quite bluntly, in The Daily Beast, minority doctors are likely to suffer the most under Affordable Care Act provisions that tie payments to patient satisfaction scores. The bottom line: patients are far more likely to rate a doctor positively if they are of the same race. Black doctors, if you look at the statistics quoted in that essay, are going to get royally screwed. They may be doing great medicine and helping their patients, but if they don’t get the ratings, their income will drop. Not only that—but it becomes less likely that they’ll be hired by hospitals, because they need to get those high satisfaction scores too.

Paying doctors more for doing good medicine makes sense, but only if you’ve got a good way to measure doctor performance. Measurements ought to reflect whether good medical decisions are being made, and whether docs are helping their patients by following good medical practice. Some elements of being a good doctor are going to be hard to measure, like listening skills and empathy and caring. But it’s clear that patient satisfaction, as it’s measured now, isn’t measuring good doctoring. Let’s abandon “patient satisfaction scores”, at least until we figure out a way to do it right.

 

*One of my books on Amazon has a one-star rating… because only one person has rated it, and that person was LOOKING FOR SOMETHING ELSE AND SAYS SHE DIDN’T EVEN READ THE BOOK. Am I bitter? Of course not. Would I appreciate your zipping over there and flaming her review? Yes, yes I would.

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4 Comments on “The dark side of patient satisfaction scores”

  1. Dr. M Says:

    The fact that any schmuck can write an anonymous review online for ANYTHING, but the company/person cannot write back without looking like a douchebag or write a review on the reviewer (“This client/patient is a drug seeker, hypochondriac, self diagnoser etc) is absolutely ridiculous.

    “Would I appreciate your zipping over there and flaming her review? Yes, yes I would.”

    Done. People are such nincompoops.

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  2. BBooey Says:

    Oh Dr. Roy, as someone who works in an institution that uses Press Ganey, I strongly disagree with you patient satisfaction scores are the herald of the apocalypse, human sacrifice, cats and dogs living together…

    To rebut your your first argument about popularity vs. quality, if you look at the article you link to for the Minnesota health system, patient volume makes up 20% of pay (e.g. the more you churn, the more you earn) but QUALITY measures make up 40%. Patient satisfaction is only 10%. The idea of doing what the patient wants even if it’s bad medicine means you’ll get your 10% but kill up to 40% of your pay – if a doctor is that malicious and stupid they need to quit medicine and run for Congress or go to law school.

    Regarding the role that race plays in the doctor-patient relationship, this is not groundbreaking news. Really, the Daily Beast and Daniella Drake’s opinion piece, in which she manages to drop the N word 5 times and states that she has, in her words, become a “Dr. Bojangles” even before ACA? As George Takai would say, “Oh my!” Hardly a thoughtful piece, and entirely speculative that her Medicare pay will be driven down significantly by patient satisfaction component. Frankly, we will have ICD 15 before the Feds get that far.

    So, what is patient satisfaction scoring about? Press Ganey and other standardized patient satisfaction tools are not Yelp! or Kudzu or Yahoo!, they’re not Twitter or Instagram or Facebook… any kook can post to those with impunity and express their craziness, like” reading the your book Flow gave our teenage son gluten intolerance, massive diarrhea , breasts and 6 weeks of menses because of the title. I give it ‘one star'” It’s a way for us as physicians to tap into what our patients are experiencing systematically and see if there are any meaningful trends that we as physicians, along with our healthcare teams of nurses, MA’s, receptionists, managers, etc. Satisfaction with the registration experience go down for 3 straight months? Maybe it’s the new hire who hasn’t been trained properly, or maybe you’ve been short staffed and it’s starting to show. Better to find out this way before you realize 10% of your patients have left your practice for a competitor and you need to cut staff. By using standardized tools like Press Ganey, you can monitor trends and identify areas that might need attention. For example, our office is very highly rated overall, typically 90-95% top marks as a practice month to month, but we always were falling around 50% for the question “I was informed about my wait”. As a team, we collaborated on ways to better communicate wait information to patients, and saw that number go up. When it began to slip again, we were able to see what had changed.

    In a competitive market for healthcare, which most of us operate in, patient satisfaction can and should go hand in hand with quality of care. Most patients for most conditions have choices. If the patient experience in the office is consistently negative and the doctor is consistently a d-bag, good care’s not happening there.

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  3. Dr. Roy Says:

    Dr. Booey says “patient satisfaction can and should go hand in hand with quality of care.” A nice sentiment, but I’m not sure there’s any empirical evidence that it’s true. IF outcomes are a good proxy for quality care, it looks like patients with the highest satisfaction scores are actually the least healthy and the most likely to die:

    https://pediatricinsider.wordpress.com/2012/08/20/patient-satisfaction-versus-good-health/

    Though the proportion of income tied to satisfaction scores may be low, it seems to be affecting doctor behavior in unintended ways:

    http://www.kevinmd.com/blog/2013/11/focus-patient-satisfaction-sick.html
    http://www.thedailybeast.com/articles/2014/05/21/the-mask-your-doctor-hides-behind.html

    Dr. Booey points out that Press Ganey scores have helped his group identify a specific area that could be improved. I’m assuming here he works with a large institution that can afford regular Press Ganey reviews– and perhaps that is the trend we’ll face, with more and more docs working for big hospital systems. I work for a small group, owned by myself, that couldn’t possibly afford that– and in a small office like mine, if a new hire or doc is a douche-bag, I know it right away.

    One of the bloggers linked above points out that in his ER, they get no feedback about why their Press Ganey scores were low, and no opportunity to improve. I suppose you could say that Press Ganey scores are just a tool, and it’s up to the hospitals to use them correctly. One could also make the case that it’s not the gun’s fault that someone gets killed (wait… forget I said that… let’s not go there…)

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  4. Dr. Roy Says:

    Thanks Dr. M! I’ve reported that review as abusive several times, but no reply from Amazon. Not that it matters that much– the book was really just written for my then-11-year-old daughter, and I never really thought anyone else would buy it. Still, a one-star review rankles!

    More seriously, Dr. Booey does make a reasonable point that yelp, facebook, etc aren’t the same as formal surveys from Press Ganey et al, who at least make some effort to make sure that reviewers are actual patients instead of, say, ex-spouses or employees of competitors. Still, I wonder, in our evolving big data world, how long that distinction will hold. Is there a company waiting in the wings that will offer “data” to insurers and government payers that’s based on internet ratings? I would imagine such information would be much cheaper to collect, and could then be sold at cut-rates to the payers. Do you think the payers will continue to pay top-dollar for Press Ganey scores when someone else is offering cheaper data that lets them cut fees just as easily? Hmm… I smell a business opportunity…

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