After an inpatient stay in which a patient was treated by the best clinicians and went home with a positive medical outcome, it may come as a surprise that this recipient of “good” care isn’t happy.
If the room was dirty, the hallway noisy or the nurse inconsiderate, the hospital will get a low evaluation on the Hospital Consumer Assessment of Healthcare Providers and Systems survey, known mainly by its acronym of HCAHPS. As a result of the Centers for Medicare and Medicaid Services’ new Hospital Inpatient Value-Based Purchasing program, that score will soon translate into lost money for the hospital. Some hospitals think the above scenario proves that HCAHPS scores don’t reflect care quality. Others gripe about whether the program is fair to larger institutions, those in regions where people aren’t easily satisfied or to teaching hospitals.
There is some validity to some of the complaints, but I would prefer to see people begin to focus on improving their relationships with patients, regardless of percentile rankings or value-based purchasing points. This is a business imperative in the age of transparency and consumerism, even if it weren’t important from a reimbursement perspective.
The change from pay for reporting to pay for performance under Medicare means that by 2017, 2 percent of all Medicare payment will be withheld, with hospitals having to earn back all or a portion of it, depending on how they score on measures of quality, including HCAHPS, which amounts to 30 percent of the total score. It’s true that linking payments to patient satisfaction scores may hurt hospitals in regions where patients render less-positive opinions about the care they receive. States with lower scores include Maryland, New Jersey, Hawaii and New York. Nationally 67 percent of patients give their hospitals a top rating, but in New York, for example, only 59 percent do. That may not sound like a big deal, but when many facilities are tightly grouped around a small range in scores, it can make all the difference.
One theory about the regional variation in scores is that hospitals in those regions treat lots of patients with multiple comorbidities, and that possibly can be associated with less-than-desirable reviews. CMS says that it will adjust its ratings to take those things into account. However, some research shows that teaching hospitals and other large hospitals seem to get worse patient evaluations than do community hospitals, a factor that CMS says it will not take into account in weighting scores.
Also, cultural factors may also play a role. People in the Northeast may be harder to please than Midwesterners and Southerners. That may explain why hospitals in South Dakota, Nebraska, Louisiana and Iowa seem to always be at the top of the HCAHPS database.
“Because we have such cultural diversity, such literacy variability and such large and very complex hospitals, for us to always hit it out of the park is very difficult,” Jaclyn Mucaria, a senior vice president at New York-Presbyterian Hospital told Kaiser Health News recently. “There’s another theory—that we New Yorkers are very hard to please, whether it’s in a hotel or a restaurant or a hospital. For somebody to really rave about something is an anomaly.”
Paul Cleary, dean of the Yale School of Public Health, says that academic centers often fall short of perfection because their patients need multiple medications and see lots of specialists. That leaves plenty of room for oversights and confusion. In New York City three nationally recognized teaching hospitals—Beth Israel Medical Center, NYU Langone Medical Center and Mount Sinai Medical Center—scored below average on their patient satisfaction scores.
Dr. James Merlino, chief experience officer of the Cleveland Clinic, feels that focusing on patient satisfaction is the right thing to do but he also cautions that it's also necessary to pick the right metrics as well as hold hospitals accountable for the things they can control.
Over the years I have talked to a number of top healthcare leaders who have told me that they feel treating patients as customers hasn't been high on their priority list with all the other matters they have to contend with running quality healthcare institutions.
Whatever you think about HCAHPS, that attitude won’t cut it anymore. Today, all hospitals better brush up on the basics of treating customers with dignity and respect along with giving them quality healthcare. It's a different game that’s changing at a rapid pace, and those that don’t keep up are destined for a rude awakening. Customers, after all, are the very lifeblood of any business, and healthcare today is a big business.