Although patient relationships consistently rank at the top of physician-satisfaction surveys, that relationship is changing. Patients, their demands, and time pressure are conspiring to sap physician autonomy.
According to consultant PwC, five trends are driving the transformation from patient encounter to “customer experience.”
- Increased cost sharing. Higher deductibles and tiered pricing have forced patients to take a more active role in their healthcare decisions.
- The push for value by payers and the government. There is a greater focus on cost containment, quality and transparency.
- “On-demand” health care. Nearly 1 out of 4 patients said they had sought treatment at a retail clinic in 2011.
- Information access. There is a decentralization of power as more patients seek healthcare information on the Internet.
- Health reform. An estimated 30 million newly insured Americans will be seeking care, and standardized insurance means providers will have to differentiate themselves on the basis of customer service.
Physicians are being judged by new standards. The Institute of Medicine defined patient-centered care as taking into account patient preferences, needs, and values. It is easy to confuse that with patient satisfaction, which has its roots in consumer marketing. Patient satisfaction, say physicians Joel Kupfer and Edward Bond, means the customer’s expectations were met or exceeded. If not, the service is deemed low quality.
Patient satisfaction is important, they say, because it means physicians are providing comfort, support, and education. However, patient satisfaction and patient-centeredness differ, because physicians are not obligated to satisfy patients’ demands in the latter.
Many physicians dislike the morphing of patients into “customers.” Yet it is clear that the consumer-focused practices of other retail industries are seeping into the exam room. In an online survey of 6,000 consumers, PwC found that only 8 percent ranked price as the top factor in choosing a physician despite the fact that it was the No. 1 priority for more than half the respondents in shopping for travel, health insurance, or retail goods. Personal recommendations were more than twice as likely to influence the purchase of healthcare services as any other consumer purchase. Nine out of 10 said they would be willing to recommend a physician or hospital after a positive experience.
Millions of patients rely on physician ratings websites such as Healthgrades.com, Vitals.com, and Rate MDs.com. Half of Americans go online to research health information, and about 40 percent use websites that review physicians.
However, each rating is based on an average of only 2.4 patients. That means one disgruntled patient can skew the ratings significantly. There is no significant difference in median number of reviews based on gender, city size or U.S. region.
Picking a physician is not like buying a commodity. Physician services clearly defy simple ratings. However, that does not stop those who try to provide them. Consumer Reports rated 487 Massachusetts primary care and pediatric practices in its July 2012 edition, assigning scores from 1 to 4 in each of five categories related to patient experience.
The state’s physicians seemed to be comfortable with the ratings’ methodology. They were based on surveys completed by more than 64,000 adults, and ratings had to reach a statistically reliable level threshold for an individual physician to be included.
Even with anonymity, raters tend to give their physicians rave reviews. A study examined more than 386,000 physician ratings posted on the RateMDs.com website between 2005 and 2010. Begun in 2004, the website has the most user-submitted reviews. About 250,000 U.S. doctors have been rated at least once on the site, according to RateMDs.com co-founder John Swapceinski.
RateMDs.com assigns physicians an overall rating of 1 to 5 based on patient assessments of their knowledge and helpfulness. Physicians received an average quality rating of 3.93 out of 5. Nearly half received a perfect 5 rating.
Consumers are not particularly adept at figuring out what excellent care is. In a study of breast-cancer patients, 55 percent said they had received “excellent” care—even though 88 percent got treatment that was consistent with the best-treatment guidelines.
Respondents seemed to be more focused on the treatment process—such as how well providers communicated, and the ease of service.
However, physician performance may not affect customer loyalty. In focus groups conducted for the Robert Wood Johnson Foundation, patients consistently said that they would not switch their physician even if the personal chemistry was poor.
What patients want most are well-trained physicians who offer easy access and spend time with them in exam rooms. These qualitative factors are much more prevalent in health care than in other consumer settings.
Many doctors already have trouble turning down patient requests. More than 1 out of 3 say they would yield to a patient who asks for a clinically unwarranted magnetic resonance imaging exam.
In October 2013, the Centers for Medicare and Medicaid Services (CMS) began withholding 1 percent of hospital reimbursement to be redistributed as incentives to the hospitals with the highest performance-measure scores. Patient-satisfaction metrics account for 30 percent of the score. The percentage of reimbursement withheld will rise to 2 percent in 2017.
Evidence indicates that physicians—especially those employed by hospital systems—have been altering the way they practice to please the patient.
Consider these results from an Emergency Physicians Monthly survey:
- More than 16 percent of medical professionals had their employment threatened by low patient satisfaction scores.
- 48 percent of providers said they altered medical treatment because of the potential for a negative report on a patient satisfaction survey, with 10 percent of those admitting they provided medically unnecessary care.
- In a South Carolina Medical Association survey, more than half of physicians said they had ordered tests they considered inappropriate, and nearly half said they had improperly prescribed antibiotics or narcotic pain medication, because of patient satisfaction surveys.
A team of University of California at Davis researchers found that people who are the most satisfied with their doctors are more likely to be hospitalized, accumulate more healthcare and drug expenditures, and have higher death rates than patients who are less satisfied with their care. The researchers speculated that the higher death rates were a result of patients putting themselves in harm’s way more often because of excess treatment.
“Patient satisfaction is a widely emphasized indicator of healthcare quality, but our study calls into question whether increased patient satisfaction, as currently measured and used, is a wise goal in and of itself,” Joshua Fenton, associate professor in the UC Davis Department of Family and Community Medicine and lead author of the study, said in a statement.
“Doctors may order requested tests or treatments to satisfy patients rather than out of medical necessity, which may expose patients to risks without benefits,” he said. “A better approach is to explain carefully why a test or treatment isn’t needed, but that takes time, which is in short supply during primary-care visits.”
In an editorial accompanying the UC-Davis study in the Archives of Internal Medicine, Dr. Brenda Sirovich wrote, “Numerous studies have found that patients are consistently highly satisfied with one of the most common downsides of medical care–false-positive test results and the downstream events that follow. Almost any unnecessary or discretionary test has a good chance of detecting an abnormality.”
She wrote, “The direct relationship between customer satisfaction and subsequent consumption is doctrine in commerce and business. ‘The customer is always right,’ a phrase likely coined by Marshall Field, the department store magnate, in the late 19th century, is a credo that we, as consumers, may wish we encountered more often. Is health care any different? Apparently not.”
The above is an excerpt from his new book So Long, Marcus Welby, M.D.: How Today’s Health Care Is Suffocating Independent Physicians—and How Some Changed to Thrive. D Healthcare Daily founding editor Steve Jacob draws on dozens of interviews and more than 500 published sources to cover these issues and describe how the landscape is changing for doctors.