Should Patients Determine How Much Hospitals Get Paid?

Op-ed: Talking openly with patients is necessary to improve medicine, but what happens when a tough conversation gets factored into payment?

This past October, the Centers for Medicare and Medicaid Services started linking hospital reimbursements paid to how well they perform on the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS, survey. HCAHPS measures how satisfied patients were with a broad range of items which supposedly reflect the overall “hospital experience.” Among these are the quality of communication with the different healthcare providers; how clean (and quiet) the hospital was; and how responsive the staff was to the patient’s needs.

The rationale behind tying reimbursements to patient satisfaction is simple: healthcare is, after all, a service, and providers and hospitals should be rewarded for providing excellent service to consumers, in this case, patients.

Focusing in on the portion of the survey which assesses communication, there is a broad body of research demonstrating a connection between good communication, especially between patients and physicians, and better health outcomes. These include fewer adverse events within the hospital setting, such as medication errors and errors of medical care (for example, having an unnecessary procedure done). In the outpatient arena, better communication between doctors and patients is also linked to higher rates of medical adherence, which in turn leads to better outcomes, fewer hospitalizations, and lower costs overall.

But is tying reimbursements to this kind of a survey really the best way to go about improving communication between physicians and patients? And are patients the most reliable in determining the quality of this communication?

A fascinating study by Dr. Janet Weeks of the Dana Farber Cancer Institute and colleagues, published in the New England Journal of Medicine in July 2012, demonstrated that some patients have a tendency to conflate the message with the messenger (as many of us do). The researchers interviewed almost 1,200 patients with advanced, incurable, cancer and asked them about their expectations from chemotherapy. Those patients who characterized the communication between themselves and their physicians as “very favorable” were more likely to believe that they could be cured by the chemotherapy than those who did not.  (Our Kevin Charles Redmon wrote more about Weeks’ study here.)

This is concerning, because it indicates that being firmer with patients about following best practices and not pursuing unrealistic treatments, or tests that are not cost-effective such as MRI scans for lower back pain (avoiding unnecessary imaging studies in patients with lower back pain could save as much as $300 million annually), could actually result in lower patient satisfaction scores, and thereby to reduced payment for services rendered.

Quality improvement in healthcare is important, as are the savings which would presumably follow. Improvement in physician-patient communication is a central part of that, especially surrounding discharge instructions, where studies have shown significant gaps between patient comprehension of physicians’ discharge instructions and what the patients themselves understood. With almost one-fifth of Medicare patients being re-admitted to the hospital within 30 days of discharge, costing an estimated $17.4 billion annually, this is clearly an area which needs a lot of work. Improving communication between physicians and patients at the time of discharge might be accomplished by training physicians and other healthcare providers in better communication skills, perhaps in workshops that utilize simulated patient encounters, in which the participants are observed by and receive real-time feedback from trained facilitators.

This is likely to prove more effective, and more long-lasting, than merely determining the quality of communication through arbitrary assessments made by patients that may not accurately reflect the true measure of physician-patient communication as is hoped for. Providing financial incentives to create (and sustain) such workshops will almost certainly prove to be cost-effective if, as anticipated, bounce-back hospitalization rates decline as a result. This is certainly something which can be measured.

In my own practice I care for lots of asthmatic children, many of whom are referred to see me following an acute hospitalization. I am often struck by the gaps between the discharge instructions pertaining to when and how medications should be taken as they appear in the patient’s discharge summary (which may have been issued at any one of the 20-plus hospitals in the area), and what the child is actually being given. Despite good intentions on the part of the child’s parents and the discharging physician there were still misunderstandings which, had they not been identified sooner, would likely have resulted in a readmission later. This is an area which certainly needs to be addressed, but constructively, rather than punitively, as seems to be the choice that has been made.