Patient Satisfaction & Patient-Centered Care: Necessary but Not Equal bit.ly/MN7Yan JAMA Highly satisfied patients had worse outcomes
— Jan Henderson (@HealthCulture) July 26, 2012
Why would patients who report greater satisfaction with their health care be worse off medically? This JAMA article, Patient Satisfaction & Patient-Centered Care: Necessary but Not Equal, offers an explanation that makes sense. It points to the commercialization of health care – treating the patient as a consumer – as the villain. (All quotations in what follows are from this article.)
The patient (consumer) satisfaction survey
In the US, many doctors are evaluated and rewarded based on patient satisfaction surveys. Motivated to produce high patient satisfaction scores, doctors are inclined to order more diagnostic tests. Why? It’s more than a simple desire to please the patient.
When physicians’ performance evaluations and incomes are tied to patient satisfaction, the situation becomes ripe for overuse and misuse of diagnostic and therapeutic procedures because it allows the physician to rationalize decision making in terms of patient satisfaction.
Pleasing a patient is a conscious, individualized choice. Rationalized decision making can easily become an automatic habit that requires no additional thought.
In addition to overuse of diagnostic tests, doctors are also accused of overprescribing many categories of drugs (antibiotics, statins, pain killers, antidepressants). Patients in turn are blamed for expecting an office visit to result in a prescription. When patients are free to change doctors, and doctors in private practice depend on patients for their income, satisfying patients appears as logical as the desire for economic survival.
Here’s where the harm comes in: Patients who receive more diagnostic tests are more likely to be overdiagnosed, leading to unnecessary and possibly harmful procedures. Patients who take more drugs are more likely to suffer the potentially harmful side-effects that accompany any pharmaceutical product. So the patient is highly satisfied, but worse off.
[H]ighly satisfied patients had higher health care use and worse outcomes, even though they rated their own health as excellent.
Medicine as a profit-driven business
I was pleased to see that this article, in The Journal of the American Medical Association no less, addressed the commercialization of health care. The article comes right out and says that using patient satisfaction as “perhaps the most desirable medical outcome” (emphasis added) originates in consumer marketing. Hospitals and HMOs are especially dedicated to the value of patient satisfaction. The companies that create and supply patient satisfaction surveys maintain there is a ”significant association” between higher satisfaction and fewer malpractice claims. They even suggest that satisfied patients may benefit medically from the placebo effect.
Dr. Arnold Relman, a former editor of The New England Journal of Medicine and originator of the term ‘medical-industrial complex,’ is one of those who argues that medicine was never intended to become a profit-driven business. There are significant differences between consumers of ordinary goods and services and patients seeking medical care. I list a number of the more obvious differences here. The JAMA article mentions two that relate directly to patient satisfaction.
One, it is difficult for patients to evaluate the quality of their care. For example, patients may overemphasize the value of physician behavior that can be objectively measured (the number of tests ordered), but dismiss and not value more subjective behavior (advice to stop smoking or lose weight). There is an asymmetry of knowledge – a patient can’t possibly be as informed as a doctor about what’s wrong and what’s needed.
Two, unlike most business transactions, the majority of patients do not pay directly for the services they receive. Payments happen through a third party, most commonly in the US through an insurance company. In a business transaction, the consumer experiences an immediate and direct trade-off between the cost and the quality of the service rendered. If you pay more, you expect more. This expectation acts as a control mechanism on costs. In medicine, this trade-off is absent. The result: “neither patients nor payers make decisions with a holistic view of the trade-offs involved,” where holistic includes both the best interests of the patient and the financial viability of health care.
From a business perspective, greater customer satisfaction should improve profits.
Corporate interest in customer satisfaction has focused on improving corporate profits through the satisfaction-profit chain by creating customer retention, loyalty, and repeat business.
Corporatized, profit-driven medicine can achieve all three of these goals. Patients are not well-served, however, when the commercialized, privatized business model is applied to health care. The result is superficially satisfied patients who make greater use of the health care system at the expense of their own health.
From MD to MBA: The business of primary care
Patient safety and corporate profits
On healthism, the social determinants of health, conformity, & embracing the abnormal: (2) Economics & the socio-political
John M. Kupfer, Edward U. Bond, Patient Satisfaction & Patient-Centered Care: Necessary but Not Equal, JAMA, July 11, 2012, Vol 308, No 2, pp 139-140
Melvin F. Hall, Looking to Improve Financial Results? Start by Listening to Patients, Healthcare Financial Management Association
Arnold Relman, A Second Opinion: Rescuing America’s Health Care (2007)