As hospitals, insurance companies and policy makers seek to improve healthcare quality and reduce rising medical costs, one important metric used to assess clinicians hinges on how patients feel about their healthcare experience. Many healthcare providers and policy makers fear that increased pressure to please patients -- and ensure high satisfaction ratings as a result -- could lead to overuse of low-value care that doesn't provide any clinical benefit while unnecessarily ratcheting up medical bills.
But new research from the University of Chicago and Harvard Medical School may alleviate some of those concerns. The study, published May 28 in JAMA Internal Medicine, found no relationship between favorable patient ratings and exposure to more low-value care.
"Some believe that much low-value care is provided by doctors because they feel like they have to appease patients. This worry has become bigger as patient ratings are increasingly used in new payment models and public reporting of healthcare rankings," said lead author Prachi Sanghavi, PhD, Assistant Professor of Public Health Sciences at UChicago. "For example, if a patient asks for extra testing or screening when it's not medically indicated, should doctors worry they will be rated poorly if they don't comply? At the same time, physicians feel pressure to reduce unnecessary testing and procedures when possible, because they are wasteful and can lead to harm downstream."
At least one often-cited study supports the concern that a focus on patient ratings will lead to more low-value care, finding patients with higher satisfaction ratings had higher odds of inpatient admission, higher healthcare and prescription drug costs and higher mortality. This study implied that catering to patient satisfaction may lead to worse outcomes. But, Sanghavi says, these results are likely a reflection of the methods used in the study.
"The past research didn't adequately adjust for certain key factors, like how sick a patient might be, which could be a confounding factor," said Sanghavi. "For example, people who are chronically or terminally ill may use more care and may develop closer relationships with their doctors, which could in turn lead to higher patient satisfaction ratings."
In their new study, Sanghavi and her team examined data from the federal Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, which uses patient-provided observations to measure things like communication with a physician, timeliness of scheduling an appointment and time spent in the waiting room. They also analyzed Medicare claims to measure the amount of low-value care received by a physician's patient panel. Unlike past studies, the researchers' approach relied on sampling independence and little overlap between the patients in the CAHPS and claims datasets. With this innovative methodology, the researchers were able to eliminate patient-level, unconnected factors that could influence the results and gain a less-biased look at the relationship between patient satisfaction and low-value care exposure.
"While we found a wide range of low-value care across physician patient panels, there was no systematic association between low-value care exposure and favorable patient ratings," said Sanghavi. "So the physicians whose patients get more low-value care are not getting higher ratings."
These results, the investigators say, should help ease the concern that reducing the number of unnecessary care offerings will negatively impact patients' opinions of their physicians or healthcare organizations.
"In short, the concern is overblown," said study co-investigator Michael McWilliams, Professor of Health Care Policy at Harvard Medical School and a general internist at Brigham and Women's Hospital. "Whether it's because less wasteful physicians are adept at informing patients why a requested test or procedure is unnecessary, or because most low-value care is due to provider practice patterns and not patient demand, we should be reassured that we can tackle waste in the system without great patient backlash or flunking providers on their 'scorecards.'"
The researchers said they weren't surprised by the findings, since previous studies relied so heavily on anecdotal evidence.
"In fact, it is not settled whether patients even advocate for low-value services," Sanghavi said. "Either way, it is reasonable to imagine patients base their experience ratings on a range of quality dimensions and not just on how well their physicians give in to demands, should they be making them."
Understanding how patient experiences and ratings are impacted by the types of care they receive has important implications for future policies and funding models geared at reducing wasteful healthcare spending while improving the overall quality of care.
"These results should help alleviate the stress that physicians may feel around possibly leaving patients dissatisfied because they didn't do something the patient asked for," said Sanghavi. "It should also relieve pressure to provide unnecessary care in order to boost ratings."