If You Had to Choose, Would You Rather be Pleased with Customer Service, or Alive?

Background:

An article published on Medscape recently discussed some of the drawbacks of the new focus in healthcare. The government in America has decided that what healthcare providers get paid partially depends on how much their patients like them. It is their attempt to get rid of the "fee for service" type of payment that has ruled until now. According to them, the current system rewards for doing things. Thus, the onslaught of unnecessary procedures. It is thought that doctors and hospitals will order things like expensive MRI's when there really isn't a good reason for them just because they can bill for it.

So the new idea is that reimbursement should be based on how happy the patient is. If surveys show that your patients love you, a more substantial check is in the mail. If you happen to care for a more unhappy population, better start pinching pennies.

Summary:

This article was written by a physician who sees the problems with this arrangement. The article can be found here. However, you may be required to put in a username and password. Since most people probably don't have that, here is a quick summary:

The physician in the article had presented on RSV at a conference, emphasizing that antibiotics should not be given for this viral disease. The reasoning is that antibiotics don't attack viruses, they attack bacteria. Also, giving antibiotics for unnecessary reasons causes resistance for the individual and society. Later, he had conversations with multiple other physicians who stated that they knew this was true, but their patient's and the parents weren't happy unless they got antibiotics. Since reimbursement is tied to patient satisfaction, physicians felt that they needed to give out the antibiotics. One said his satisfaction scores rose 7% just by giving antibiotics to anyone who came in with some kind of cold or cough.

The author states "I believe that this little-known company, Press Ganey, [the company organizing the surveys] from South Bend, Indiana, has become a bigger threat to the practice of good medicine than trial lawyers." He argues that this system encourages healthcare professionals to provide care based on what the patient wants, rather than what they need. Often, these two things do not match. He also cites research that shows that the most satisfied patients get the most care and are the most likely to die. In other words, over-treating someone because they want it, just to make them happy is not beneficial. I might add, financially or physically. 

To prove his point a little more, the author tells of a time a woman came in asking for a medication for her prostate, just because he had a coupon for it. He also points out that it discourages physicians from approaching sensitive topics, such as obesity and smoking. A smoker doesn't want to be told that smoking is causing their illness. So if you want full reimbursement, don't address that. Just treat the problem without encouraging treatment of the cause.

Now I hope I have summarized fairly. Please don't get the impression that they physician was at all implying that the average patient is stupid and doesn't know anything. Simply that they don't have the training and background necessary to understand why they do and do not need certain things.

My Two Cents:

As I read through the comments, I saw mostly agreements to the fact that this is a problem. Granted, only medical professionals are allowed to comment. That does make the discussion rather one-sided. Being a nurse myself, I do very much agree that patient satisfaction truly has little bearing on whether or not good medical care is given. Some people say they would rather have a nice doctor who may not be as expert as another. In many serious situations, I would rather have a complete jerk of a doctor if he was the best in his field. But just because he isn't nice to me doesn't mean he deserves to be compensated less. In fact, if he does a better job, I would be willing to pay more.

From the hospital perspective, there are not many situations that someone is happy to be there. Perhaps if you have just had a happy healthy baby. But other than that, most people would rather not be in that particular predicament. That makes for sad, grumpy people filling out the surveys that determine pay. Pretty inaccurate and unfair in my opinion. Plus if even one thing is not up to par, say the food is bad, people tend to perceive that as being a total bad experience, and when given the chance to comment make it known. They often overlook the other great things that happened. (For instance, if their life was saved).

All that being said, I think some healthcare professionals take an approach that is unfair to their patients. For instance, the article stated that "Patients aren't the best judge of what is best for them." While that is often the case, I do not entirely agree. Every person needs to be heard. Every body is different. Because of that, no one prescribing or carrying out care for another person can assume that they are always right about what is going on or what the best treatment is. And I don't think that it is fair to say that the reason patient satisfaction shouldn't drive reimbursement is because patient's don't know what's best for them. In reality, it is simply not a measure of quality of care. But that doesn't mean your doctor is always right.

Here is one comment I especially appreciated:

"I agree that we should do what is right, but we must not forget to tell the patient WHY we made our decision."

THANK YOU. I simply think this is such an important point. Patient's may not have the training and background that physicians do, but most are capable of learning about their own specific ailments. In my opinion, providing health care is a partnership, not a dictatorship. Best results will be achieved if the provider of care explains what is happening, what the options are, and what each option would mean to a particular individual. Then a discussion can ensue where the patient can weigh the risks and benefits for them. It then becomes their own decision whether or not to take the medication, go through with the procedure, or begin the treatment. In fact, this approach may provide the best care for each patient while maintaining high satisfaction for most.

It is also something that rarely happens. I think there are a lot of things patients would not ask for or want if we were completely honest and upfront with them about the risks. I also think people have a false sense that everything that happens in healthcare is safe. Even if you do mention the fact that a procedure can cause severe infection, bleeding, loss of function or even death, people don't take you seriously. Better education on the part of the professionals would really help rather than hurt.

Just as an example, whenever I started a patient on a new medication,  I would print out a 3-5 page information packet on the new drug. I would highlight under "indications" the reason it had been prescribed for that patient. Then I would highlight other important information, especially potential side effects. There were so many times people were so surprised to hear all of the problems medications can cause. It was as if they never imagined that something prescribed by their doctor could hurt them in any way. But they can. I think if we were upfront about these possibilities, more patients would pay attention to what they are taking. Hopefully more would have a relationship with their pharmacist and always have him/her check their list of meds when a new one is added for possible interactions. This is just one example of an area where health care providers do not share enough information with their patients.

As another side note, physicians should not have to feel that they have to provide care they don't agree with. Patients should have a choice, and their providers should have a choice. If the two do not match, that partnership should end. It should be a kind and understanding separation, not one of judgement after a battle of wills. No doctor knows what is best for everyone. Their opinion of what is "best" will always be tainted by their own views of life, death, illness, and the social issues that surround these and similar topics.

Let us all show each other some respect and work as teams instead of competing against one another to see who is "right."