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Topics in Practice Management
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Patient Satisfaction Why and How Patients Grade You and Your Pulmonary Practice Stacey M. Kassutto, MD; and Rupal J. Shah, MD, MSCE
Patient satisfaction is an important factor for consideration in pulmonary practice management. Although evidence regarding the correlation of patient satisfaction with care quality remains mixed, there is an increasing national emphasis on the importance of patient experience in physician reimbursement, credentialing, and public opinion. The introduction of the Affordable Care Act and value-based care purchasing has tied a portion of reimbursement to patient experience surveys and other metrics related to care quality rather than quantity. Through nationally recognized assessments such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys and easily accessible websites such as RateMD and Yelp, patient opinion of care quality is more widely available and more important to pulmonary practice than ever before. Physician credentialing may also be impacted by the American Board of Internal Medicine’s Maintenance of Certification program and potential future requirements for physicians to assess the patient experience to maintain certification. In the continually evolving health-care delivery, credentialing, and reimbursement climate, a thorough understanding of the increasing importance of patient satisfaction as well as strategies for successfully approaching this issue are essential to modern pulmonary inpatient and outCHEST 2015; 148(3):833-838
patient practice management.
ACA 5 Affordable Care Act; CAHPS 5 Consumer Assessment of Healthcare Providers and Systems; CMS 5 Centers for Medicare & Medicaid Services; MOC 5 Maintenance of Certification; MPFS 5 Medicare Physician Fee Schedule
ABBREVIATIONS:
Health-care quality is an important focus in the medical community. According to the Institute of Medicine’s 2001 report, patient-centered care is a key element of high-quality health care and is cited in the institute’s key recommendations for improving the 21st-century health-care system.1 However, a patient’s perception of quality care may differ from that of the physician who remains at the center of the increasingly quality-driven and perfor-
Manuscript received January 29, 2015; revision accepted March 5, 2015; originally published Online First March 26, 2015. AFFILIATIONS: From the Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. CORRESPONDENCE TO: Stacey M. Kassutto, MD, Perelman School of Medicine at the University of Pennsylvania, 839 W Gates, 3400 Spruce St, Philadelphia, PA 19104; e-mail: [email protected]
journal.publications.chestnet.org
mance-driven health-care industry. Standardized governmental surveys and nationally recognized websites focused on patient satisfaction continue to gain prominence and importance. Understanding how patients evaluate their care and its impact on inpatient and outpatient clinical practice, physician credentialing, and reimbursement is essential to the pulmonologist practicing in today’s continually evolving health-care climate.
© 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.15-0223
833
Patient Satisfaction and Care Quality Health-care quality is defined in many different ways. Although patient experience surveys are becoming increasingly important in physician reimbursement and credentialing, the relationship between patient satisfaction, health-care utilization, and clinical outcomes remains unclear.2 Many physicians are concerned about the impact that the movement to improve patient satisfaction will have on clinical practice, citing concerns about pressures to prescribe unnecessary tests or medications in the name of improved satisfaction scores.3,4 Fenton et al2 showed that respondents with the highest patient satisfaction scores had a higher likelihood of hospital admission, greater health-care expenditures, and higher mortality. Others suggest patient experience is only modestly correlated with processes of care and that no significant association with clinical outcomes exists.5 Conversely, many believe that patient satisfaction is indeed an important aspect of quality care, citing studies indicating that patient satisfaction may indeed correlate with the quality of clinical care delivered. Hospitals with higher patient satisfaction scores performed better on measures of care quality for myocardial infarction and pneumonia as compared with hospitals with lower patient ratings.6 There may also be a correlation between higher satisfaction scores, greater patient adherence to physician recommendations, lower odds of ED room visits, and loyalty to a physician’s practice.2,7,8 As improved measures of patient satisfaction are developed, study of the relationship with clinical outcomes will be important in determining whether patient experience scores rise or fall in future importance.
Physician Reimbursement and Value-Based Care In spite of the mixed evidence, physicians aspire to provide high-quality care and build a positive doctorpatient relationship. To reward behavior focused on care quality, the Affordable Care Act (ACA) of 2010 promoted a shift from reimbursement based on “fee-for service” to a “pay for performance” model with the goal of moving toward a physician reimbursement system that “rewards value rather than volume.” Section 3007 of the ACA mandated that the Centers for Medicare & Medicaid Services (CMS) begin applying a value modifier that incorporates both cost and quality data to the Medicare Physician Fee Schedule (MPFS) by 2015.9 Defining value-based care is complex and multifaceted. The MPFS includes a value-based payment modifier linked to care quality. The value-based care purchasing
834 Topics in Practice Management
program links 30% of a hospital’s total performance score to the patient experience of care domain. The remaining 70% of the total performance score is linked to clinical processes of care (20%), patient outcomes (30%), and efficiency (20%) domains.10 According to the CMS, providers who satisfactorily submit Physician Quality Reporting System data during the 2014 reporting period will qualify for an incentive payment equal to 0.5% of their total estimated Part B MPFS-allowed charges during the same reporting period. However, those providers who do not satisfactorily report quality data will be subject to a 2% payment adjustment to their MPFS for services provided in 2016.11 Beginning January 1, 2015, the differential payment system mandated by the ACA and defined as part of Section 1848(p) of the Social Security Act went into effect for all groups of physicians with 100 or more eligible individual providers. The value modifier for 2015 will be calculated based on data from 2013. In 2016, groups of 10 or more providers who submit claims under a single tax identification number will be subject to the value modifier based on performance in 2014. It will be applied to all physicians beginning in January 2017. The budget for all payments will remain neutral, meaning that, in aggregate, increased payments to highperforming physicians will be offset by reduced payments to lower-performing physicians. Of note, this payment structure does not apply to physicians caring for patients in rural health clinics, federally qualified health centers or critical access hospitals.9,11-15 Although value-based care purchasing only applies to CMS reimbursements, other payers will likely continue to follow CMS’s lead. Major health plans such as Blue Cross Blue Shield of Massachusetts and HealthPlus of Michigan and multistakeholder organizations such as California’s Integrated Healthcare Association have already incorporated patient experience scores into pay-for-performance measures.16 We, therefore, expect that the importance of physician quality performance measures in reimbursement from all payers will only grow as the health-care industry continues to emphasize quality over quantity of care. Although the payment system is complex and evolving, an understanding of the fundamentals of value-based purchasing is essential for the physician who aims to maximize reimbursements and the financial success of his or her practice.
National Standardized Surveys Given the growing financial importance of patient experience metrics, it is important to understand how these
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data are collected, organized, and reported at the national level. CMS administers several different patient experience surveys that assess patient ratings of health care in a variety of settings. These surveys include ratings of hospitals, home health care, and physicians as well as health and drug plans. Through the Physician Quality Reporting System and the application of the value-based modifier, providers are financially incentivized to report quality information which will in turn be publicly reported and compared with national benchmarks and past performance by CMS. The Consumer Assessment of Healthcare Providers and Systems Surveys
Many of the surveys used by CMS are from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. These surveys are developed and maintained by the US Agency for Healthcare Research and Quality. The hospital CAHPS survey was first implemented in 2006 as an instrument to measure patients’ perspectives on hospital care. The current hospital CAHPS survey is a 32-item questionnaire administered to a random sample of adult inpatients between 48 h and 6 weeks after hospital discharge, regardless of Medicare enrollment status. It was developed by the CMS and Agency for Healthcare Research and Quality and is endorsed by the National Quality Forum. The survey underwent rigorous scientific review to assess the validity of the instrument prior to implementation.17,18 Ten of the 32 survey items have been publicly reported on the Hospital Compare website (http://www. hospitalcompare.hhs.gov) since 2008. The survey focuses on questions relating to communication with doctors and nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness and quietness of the hospital environment, and transition of care. The public reporting aspect of the collected data was designed to enhance public accountability and create incentives for hospitals to improve care quality. Although hospitals may collect their own data, this standardized survey allows for direct comparisons across all hospitals to “support consumer choice.”17 A similar survey exists for the assessment of the outpatient experience. The Clinician & Group CAHPS is composed of three different survey instruments to assess: (1) care at a specific office visit, (2) care over the prior 12 months, or (3) care over the prior 12 months in a patient-centered medical home. These questionnaires focus on access to and coordination of care, helpfulness of the office staff, provider communication, and overall
journal.publications.chestnet.org
care quality. The physician communication items assess how often the physician explains things, listens carefully, gives clear instructions, shows respect, and spends adequate time during a visit.19-22 The results are publicly reported on CMS’s Physician Compare website (http:// www.medicare.gov/physiciancompare/search.html).23 Versions of the survey also exist for pediatric patients and accountable care organizations. Accountable care organizations are designated groups of physicians, hospitals, and other health-care providers who come together voluntarily to provide coordinated care to Medicare beneficiaries with the goal of avoiding unnecessary duplication of tests and services, preventing medical errors, and spending health-care dollars more efficiently and wisely.24 A study by Quigley et al25 demonstrated that pulmonologists obtained average scores for “global physician rating” and the other five previously mentioned communication composite items on the Clinician & Group CAHPS when compared with 27 other medical and surgical subspecialty scores. Medical specialties having higher than average scores included infectious disease, rheumatology, and hematology-oncology. Showing respect for patients was noted to be the most important aspect of communication.25 If pulmonologists hope to improve patient satisfaction scores, a dedicated effort to understanding and utilizing survey data is necessary. Providers can use the online CAHPS reporting system to compare their results to benchmarks drawn from national and regional distributions, providing insight into areas that need improvement and opportunities to implement positive change. However, performing an analysis of a practice’s CAHPS data and developing quality improvement initiatives is unlikely to be feasible for all practice members due to time constraints for the busy practicing pulmonologist. Perhaps more practical in the new era of medical practice management is the designation or recruitment of one or two physicians (depending on practice size) with an interest and training in quality improvement. These individuals could best seize the opportunity to assess the available data, design quality improvement initiatives, and, as a result, perhaps increase patient satisfaction, patient recruitment, and practice revenue.
Impact on Physician Credentialing CMS is not the only national organization paying attention to patient satisfaction. The American Board of Internal Medicine instituted new Maintenance of Certification (MOC) requirements in January 2014. MOC requires physicians to participate in predetermined 835
activities at set intervals throughout the 10-year recertification cycle. Of note, an MOC in internal medicine is not required to maintain certification in pulmonary disease or critical care medicine at this time. “Patient voice” was an MOC requirement that was introduced in 2014. This requirement could be fulfilled by completing one of 21 offered practice improvement modules, which on average consisted of 25 patient satisfaction surveys, 25 chart reviews, and one practice system inventory. These were computer-based tools for physicians to conduct a confidential, self-evaluation of the medical care they provide. The patient satisfaction surveys consisted of questions related to the patient’s individual health status, current symptoms, treatment, and experience with office logistics such as refill requests and appointment scheduling.26,27 The MOC requirements very recently changed. On February 3, 2015, the American Board of Internal Medicine announced substantial modifications to its MOC program. Notably, the patient safety, patient voice, and practice assessment requirements were suspended for at least 2 years. As a result, no internist will have his or her certification status changed for not completing activities in these areas. This modification was enacted in response to many physician and medical specialty society concerns about the design and execution of the MOC program.28 The future of MOC remains somewhat unclear as requirements continue to evolve and many physicians question the utility of the requirement. In particular, the patient voice, patient safety, and practice assessment requirements are likely to undergo significant reform if they are to remain part of MOC. Although MOC is not mandatory per se, the need to maintain certification in internal medicine will vary by physician, his or her practice, and academic affiliations. It is likely, however, that patient satisfaction will continue to play a role in credentialing.
Online Physician Ratings Beyond credentialing and reimbursement, mainstream availability of patient satisfaction ratings may impact public opinion of a physician’s practice. The world of retail products and services is no stranger to consumer reviews. Since the early 20th century, organizations such as Consumer Reports have been testing and reviewing retail products and services and making findings available to the general public. More recently, websites such as Yelp, Google, Facebook, and Twitter allowed consumers to offer opinions on everything from restaurants and beauty salons to mechanics and accountants. It is, 836 Topics in Practice Management
therefore, not surprising that patients and their families are also shopping the medical market of physicians and offering personal experiences for others to read. A 2014 study from the Journal of the American Medical Association surveyed a nationally representative sample of the US population about their knowledge and use of online physician rating websites in the selection of a physician. Fifty-nine percent of respondents reported that physician rating websites were either “somewhat important” (40%) or “very important” (19%) when choosing a doctor. The study also noted that 35% had selected a physician based on positive internet reviews. Conversely, 37% of those surveyed had avoided a physician because of a negative review.29 According to a 2010 study by Lagu et al,30 33 different physician rating websites were identifiable via a simple Google search. A search performed for a random sample of 300 Boston-area physicians showed that the majority of reviews (88%) were positive, with only 6% being neutral and 6% negative. Of note, 70% of the physicians searched for had no online reviews available.30 Similarly, another study from 2012 of physician ratings on ratemd.com and yelp.com showed that the majority of online physician reviews (63%) were positive and recommended the physician to others.31 Although these websites have not been scientifically validated, it is likely that their importance will only grow as younger generations of social media-savvy patients age and increasingly seek health-care services. Future patients and employers can easily access these publicly available sites making it increasingly important for physicians to proactively monitor and manage their online presence. Performing regular Google searches and monitoring online physician rating site comments are important to maintaining a positive public perception of one’s practice. Engaging in rather than ignoring the online health-care consumer community is critical. Through the creation of professional practice websites, thoughtful responses to patient comments, and active engagement through social media, the 21st-century physician can maintain control of his or her “online story” rather than remain solely at the mercy of the digital opinion of others.32,33
Future Impact of Patient Satisfaction Although opinion on the correlation of patient satisfaction scores with clinical outcomes remains divided, it seems highly likely that ratings of patient experience will only continue to grow in importance for the practicing physician. Whether through nationally sponsored
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surveys or online physician rating websites, patients and their families are increasingly eager to access physician quality and patient satisfaction ratings to aid in the selection of a new care provider. As patient satisfaction becomes more deeply entrenched into physician reimbursement and credentialing, it is important for the provider to remain abreast of the continually evolving health-care landscape. The data provided by patient experience surveys provides an opportunity for practice improvement but the strategy for improving survey ratings will require an individualized approach for each practice, presenting a challenge in terms of time and resource allocation. We expect the requirements for both board certification and reimbursement incentives to continue to evolve over time. Overall, it seems likely that, at least for the foreseeable future, patient experience will remain an important factor in pulmonary inpatient and outpatient practice management.
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Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/ organizations whose products or services may be discussed in this article.
References 1. Corrigan JM, Donaldson MS, Kohn LT, eds. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 2. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5):405-411. 3. Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ. 1997;315(7117):1211-1214. 4. Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med. 2009;169(10):972-981. 5. Sequist TD, Schneider EC, Anastario M, et al. Quality monitoring of physicians: linking patients’ experiences of care to clinical quality and outcomes. J Gen Intern Med. 2008;23(11):1784-1790. 6. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med. 2008;359(18): 1921-1931. 7. Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826-834. 8. Safran DG, Montgomery JE, Chang H, Murphy J, Rogers WH. Switching doctors: predictors of voluntary disenrollment from a primary physician’s practice. J Fam Pract. 2001;50(2):130-136. 9. Medicare FFS Physician Feedback Program/Value-Based Payment Modifier. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Background.html. Accessed December 20, 2014. 10. HCAHPS fact sheet (CAHPS hospital survey). Centers for Medicare & Medicaid Services website. http://www.hcahpsonline.org/files/ August_2013_HCAHPS_Fact_Sheet3.pdf. Published August 2013. Accessed December 20, 2014. 11. Physician Quality Reporting System overview. Centers for Medicare & Medicaid Services website. http://www.cms.gov/Medicare/Quality-
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18.
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26. 27.
28.
29.
Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_ OverviewFactSheet_2013_08_06.pdf. Accessed December 20, 2014. Summary of 2015 physician value-based payment modifier policies. Centers for Medicare & Medicaid Services website. http://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Physician FeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf. Accessed December 20, 2014. Department of Health and Human Services: Center for Medicare & Medicaid Services. Medicare program: hospital inpatient valuebased purchasing program. 76 Federal Register 26489-26547. 2011. Physician Quality Reporting System. About PQRS. Centers for Medicare & Medicaid Services website. http://www.cms.gov/ Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ PQRS/index.html. Accessed January 12, 2015. Hospital Value-Based Purchasing Program. Centers for Medicare & Medicaid Services website. http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNProducts/ downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf. Accessed January 7, 2015. Forces driving the need to improve. Agency for Healthcare Research and Quality website. https://cahps.ahrq.gov/qualityimprovement/improvement-guide/why-improve/Need-to-Improve. html. Accessed January 7, 2015. The HCAHPS survey: frequently asked questions. Centers for Medicare & Medicaid Services website. http://www.cms.gov/ Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ HospitalQualityInits/Downloads/HospitalHCAHPSFactSheet201007. pdf. Accessed December 20, 2014. Consumer Assessment of Healthcare Providers & Systems (CAHPS). Centers for Medicare & Medicaid Services website. http://www.cms. gov/Research-Statistics-Data-and-Systems/Research/CAHPS/ index.html?redirect5/cahps/. Accessed December 20, 2014. Clinician & group. Agency for Healthcare Research and Quality website. https://cahps.ahrq.gov/Surveys-Guidance/CG/index.html. Accessed December 20, 2014. CAHPS Clinician & Group 12-Month Survey. Agency for Healthcare Research and Quality website. https://cahps.ahrq.gov/surveysguidance/cg/12-month/index.html. Accessed December 20, 2014. CAHPS Clinician & Group Visit Survey. Agency for Healthcare Research and Quality website. https://cahps.ahrq.gov/surveysguidance/cg/visit/index.html. Accessed December 20, 2014. CAHPS Clinician & Group Patient-Centered Medical Home Survey. Agency for Healthcare Research and Quality website. https://cahps.ahrq.gov/surveys-guidance/cg/pcmh/index.html. Accessed December 20, 2014. Forces driving the implementation of the CAHPS Clinician & Group Survey. Robert Wood Johnson Foundation website. http:// www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/ rwjf72668. Accessed December 20, 2014. Accountable care organizations. Centers for Medicare & Medicaid Services website. http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/ACO/index.html?redirect5/ACO/. Accessed January 7, 2015. Quigley DD, Elliott MN, Farley DO, Burkhart Q, Skootsky SA, Hays RD. Specialties differ in which aspects of doctor communication predict overall physician ratings. J Gen Intern Med. 2014; 29(3):447-454. Patient safety and patient voice. American Board of Internal Medicine website. http://www.abim.org. Accessed December 20, 2014. ABIM introduces tool for internists to review asthma care. American Board of Internal Medicine website. http://www.abim. org/news/asthma-practice-improvement-module.aspx. Accessed December 20, 2014. Baron RJ. ABIM announces immediate changes to MOC program. American Board of Internal Medicine website. http://www.abim. org/news/abim-announces-immediate-changes-to-moc-program. aspx. Accessed March 3, 2015. Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311(7):734-735.
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30. Lagu T, Hannon NS, Rothberg MB, Lindenauer PK. Patients’ evaluations of health care providers in the era of social networking: an analysis of physician-rating websites. J Gen Intern Med. 2010; 25(9):942-946. 31. López A, Detz A, Ratanawongsa N, Sarkar U. What patients say about their doctors online: a qualitative content analysis. J Gen Intern Med. 2012;27(6):685-692. 32. Campbell KR. Doctors: social media strategies to manage your identity online. KevinMD website. http://www.kevinmd.com/
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blog/2012/08/doctors-social-media-strategies-manage-identityonline.html. Published August 7, 2012. Accessed January 24, 2015. 33. Porciuncula A, Phairas D. Managing your online presence: what patients find when they ‘Google’ you affects your practice’s success. Medical Economics. October 10, 2011. http://medicaleconomics. modernmedicine.com/medical-economics/news/modernmedicine/ modern-medicine-feature-articles/managing-your-onlinepresence?id5&sk5&date5&pageID52. Accessed January 24, 2015.
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Topics in Practice Management
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Patient Satisfaction Why and How Patients Grade You and Your Pulmonary Practice Stacey M. Kassutto, MD; and Rupal J. Shah, MD, MSCE
Patient satisfaction is an important factor for consideration in pulmonary practice management. Although evidence regarding the correlation of patient satisfaction with care quality remains mixed, there is an increasing national emphasis on the importance of patient experience in physician reimbursement, credentialing, and public opinion. The introduction of the Affordable Care Act and value-based care purchasing has tied a portion of reimbursement to patient experience surveys and other metrics related to care quality rather than quantity. Through nationally recognized assessments such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys and easily accessible websites such as RateMD and Yelp, patient opinion of care quality is more widely available and more important to pulmonary practice than ever before. Physician credentialing may also be impacted by the American Board of Internal Medicine’s Maintenance of Certification program and potential future requirements for physicians to assess the patient experience to maintain certification. In the continually evolving health-care delivery, credentialing, and reimbursement climate, a thorough understanding of the increasing importance of patient satisfaction as well as strategies for successfully approaching this issue are essential to modern pulmonary inpatient and outCHEST 2015; 148(3):833-838
patient practice management.
ACA 5 Affordable Care Act; CAHPS 5 Consumer Assessment of Healthcare Providers and Systems; CMS 5 Centers for Medicare & Medicaid Services; MOC 5 Maintenance of Certification; MPFS 5 Medicare Physician Fee Schedule
ABBREVIATIONS:
Health-care quality is an important focus in the medical community. According to the Institute of Medicine’s 2001 report, patient-centered care is a key element of high-quality health care and is cited in the institute’s key recommendations for improving the 21st-century health-care system.1 However, a patient’s perception of quality care may differ from that of the physician who remains at the center of the increasingly quality-driven and perfor-
Manuscript received January 29, 2015; revision accepted March 5, 2015; originally published Online First March 26, 2015. AFFILIATIONS: From the Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. CORRESPONDENCE TO: Stacey M. Kassutto, MD, Perelman School of Medicine at the University of Pennsylvania, 839 W Gates, 3400 Spruce St, Philadelphia, PA 19104; e-mail: [email protected]
journal.publications.chestnet.org
mance-driven health-care industry. Standardized governmental surveys and nationally recognized websites focused on patient satisfaction continue to gain prominence and importance. Understanding how patients evaluate their care and its impact on inpatient and outpatient clinical practice, physician credentialing, and reimbursement is essential to the pulmonologist practicing in today’s continually evolving health-care climate.
© 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.15-0223
833
Patient Satisfaction and Care Quality Health-care quality is defined in many different ways. Although patient experience surveys are becoming increasingly important in physician reimbursement and credentialing, the relationship between patient satisfaction, health-care utilization, and clinical outcomes remains unclear.2 Many physicians are concerned about the impact that the movement to improve patient satisfaction will have on clinical practice, citing concerns about pressures to prescribe unnecessary tests or medications in the name of improved satisfaction scores.3,4 Fenton et al2 showed that respondents with the highest patient satisfaction scores had a higher likelihood of hospital admission, greater health-care expenditures, and higher mortality. Others suggest patient experience is only modestly correlated with processes of care and that no significant association with clinical outcomes exists.5 Conversely, many believe that patient satisfaction is indeed an important aspect of quality care, citing studies indicating that patient satisfaction may indeed correlate with the quality of clinical care delivered. Hospitals with higher patient satisfaction scores performed better on measures of care quality for myocardial infarction and pneumonia as compared with hospitals with lower patient ratings.6 There may also be a correlation between higher satisfaction scores, greater patient adherence to physician recommendations, lower odds of ED room visits, and loyalty to a physician’s practice.2,7,8 As improved measures of patient satisfaction are developed, study of the relationship with clinical outcomes will be important in determining whether patient experience scores rise or fall in future importance.
Physician Reimbursement and Value-Based Care In spite of the mixed evidence, physicians aspire to provide high-quality care and build a positive doctorpatient relationship. To reward behavior focused on care quality, the Affordable Care Act (ACA) of 2010 promoted a shift from reimbursement based on “fee-for service” to a “pay for performance” model with the goal of moving toward a physician reimbursement system that “rewards value rather than volume.” Section 3007 of the ACA mandated that the Centers for Medicare & Medicaid Services (CMS) begin applying a value modifier that incorporates both cost and quality data to the Medicare Physician Fee Schedule (MPFS) by 2015.9 Defining value-based care is complex and multifaceted. The MPFS includes a value-based payment modifier linked to care quality. The value-based care purchasing
834 Topics in Practice Management
program links 30% of a hospital’s total performance score to the patient experience of care domain. The remaining 70% of the total performance score is linked to clinical processes of care (20%), patient outcomes (30%), and efficiency (20%) domains.10 According to the CMS, providers who satisfactorily submit Physician Quality Reporting System data during the 2014 reporting period will qualify for an incentive payment equal to 0.5% of their total estimated Part B MPFS-allowed charges during the same reporting period. However, those providers who do not satisfactorily report quality data will be subject to a 2% payment adjustment to their MPFS for services provided in 2016.11 Beginning January 1, 2015, the differential payment system mandated by the ACA and defined as part of Section 1848(p) of the Social Security Act went into effect for all groups of physicians with 100 or more eligible individual providers. The value modifier for 2015 will be calculated based on data from 2013. In 2016, groups of 10 or more providers who submit claims under a single tax identification number will be subject to the value modifier based on performance in 2014. It will be applied to all physicians beginning in January 2017. The budget for all payments will remain neutral, meaning that, in aggregate, increased payments to highperforming physicians will be offset by reduced payments to lower-performing physicians. Of note, this payment structure does not apply to physicians caring for patients in rural health clinics, federally qualified health centers or critical access hospitals.9,11-15 Although value-based care purchasing only applies to CMS reimbursements, other payers will likely continue to follow CMS’s lead. Major health plans such as Blue Cross Blue Shield of Massachusetts and HealthPlus of Michigan and multistakeholder organizations such as California’s Integrated Healthcare Association have already incorporated patient experience scores into pay-for-performance measures.16 We, therefore, expect that the importance of physician quality performance measures in reimbursement from all payers will only grow as the health-care industry continues to emphasize quality over quantity of care. Although the payment system is complex and evolving, an understanding of the fundamentals of value-based purchasing is essential for the physician who aims to maximize reimbursements and the financial success of his or her practice.
National Standardized Surveys Given the growing financial importance of patient experience metrics, it is important to understand how these
[
148#3 CHEST SEPTEMBER 2015
]
data are collected, organized, and reported at the national level. CMS administers several different patient experience surveys that assess patient ratings of health care in a variety of settings. These surveys include ratings of hospitals, home health care, and physicians as well as health and drug plans. Through the Physician Quality Reporting System and the application of the value-based modifier, providers are financially incentivized to report quality information which will in turn be publicly reported and compared with national benchmarks and past performance by CMS. The Consumer Assessment of Healthcare Providers and Systems Surveys
Many of the surveys used by CMS are from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. These surveys are developed and maintained by the US Agency for Healthcare Research and Quality. The hospital CAHPS survey was first implemented in 2006 as an instrument to measure patients’ perspectives on hospital care. The current hospital CAHPS survey is a 32-item questionnaire administered to a random sample of adult inpatients between 48 h and 6 weeks after hospital discharge, regardless of Medicare enrollment status. It was developed by the CMS and Agency for Healthcare Research and Quality and is endorsed by the National Quality Forum. The survey underwent rigorous scientific review to assess the validity of the instrument prior to implementation.17,18 Ten of the 32 survey items have been publicly reported on the Hospital Compare website (http://www. hospitalcompare.hhs.gov) since 2008. The survey focuses on questions relating to communication with doctors and nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness and quietness of the hospital environment, and transition of care. The public reporting aspect of the collected data was designed to enhance public accountability and create incentives for hospitals to improve care quality. Although hospitals may collect their own data, this standardized survey allows for direct comparisons across all hospitals to “support consumer choice.”17 A similar survey exists for the assessment of the outpatient experience. The Clinician & Group CAHPS is composed of three different survey instruments to assess: (1) care at a specific office visit, (2) care over the prior 12 months, or (3) care over the prior 12 months in a patient-centered medical home. These questionnaires focus on access to and coordination of care, helpfulness of the office staff, provider communication, and overall
journal.publications.chestnet.org
care quality. The physician communication items assess how often the physician explains things, listens carefully, gives clear instructions, shows respect, and spends adequate time during a visit.19-22 The results are publicly reported on CMS’s Physician Compare website (http:// www.medicare.gov/physiciancompare/search.html).23 Versions of the survey also exist for pediatric patients and accountable care organizations. Accountable care organizations are designated groups of physicians, hospitals, and other health-care providers who come together voluntarily to provide coordinated care to Medicare beneficiaries with the goal of avoiding unnecessary duplication of tests and services, preventing medical errors, and spending health-care dollars more efficiently and wisely.24 A study by Quigley et al25 demonstrated that pulmonologists obtained average scores for “global physician rating” and the other five previously mentioned communication composite items on the Clinician & Group CAHPS when compared with 27 other medical and surgical subspecialty scores. Medical specialties having higher than average scores included infectious disease, rheumatology, and hematology-oncology. Showing respect for patients was noted to be the most important aspect of communication.25 If pulmonologists hope to improve patient satisfaction scores, a dedicated effort to understanding and utilizing survey data is necessary. Providers can use the online CAHPS reporting system to compare their results to benchmarks drawn from national and regional distributions, providing insight into areas that need improvement and opportunities to implement positive change. However, performing an analysis of a practice’s CAHPS data and developing quality improvement initiatives is unlikely to be feasible for all practice members due to time constraints for the busy practicing pulmonologist. Perhaps more practical in the new era of medical practice management is the designation or recruitment of one or two physicians (depending on practice size) with an interest and training in quality improvement. These individuals could best seize the opportunity to assess the available data, design quality improvement initiatives, and, as a result, perhaps increase patient satisfaction, patient recruitment, and practice revenue.
Impact on Physician Credentialing CMS is not the only national organization paying attention to patient satisfaction. The American Board of Internal Medicine instituted new Maintenance of Certification (MOC) requirements in January 2014. MOC requires physicians to participate in predetermined 835
activities at set intervals throughout the 10-year recertification cycle. Of note, an MOC in internal medicine is not required to maintain certification in pulmonary disease or critical care medicine at this time. “Patient voice” was an MOC requirement that was introduced in 2014. This requirement could be fulfilled by completing one of 21 offered practice improvement modules, which on average consisted of 25 patient satisfaction surveys, 25 chart reviews, and one practice system inventory. These were computer-based tools for physicians to conduct a confidential, self-evaluation of the medical care they provide. The patient satisfaction surveys consisted of questions related to the patient’s individual health status, current symptoms, treatment, and experience with office logistics such as refill requests and appointment scheduling.26,27 The MOC requirements very recently changed. On February 3, 2015, the American Board of Internal Medicine announced substantial modifications to its MOC program. Notably, the patient safety, patient voice, and practice assessment requirements were suspended for at least 2 years. As a result, no internist will have his or her certification status changed for not completing activities in these areas. This modification was enacted in response to many physician and medical specialty society concerns about the design and execution of the MOC program.28 The future of MOC remains somewhat unclear as requirements continue to evolve and many physicians question the utility of the requirement. In particular, the patient voice, patient safety, and practice assessment requirements are likely to undergo significant reform if they are to remain part of MOC. Although MOC is not mandatory per se, the need to maintain certification in internal medicine will vary by physician, his or her practice, and academic affiliations. It is likely, however, that patient satisfaction will continue to play a role in credentialing.
Online Physician Ratings Beyond credentialing and reimbursement, mainstream availability of patient satisfaction ratings may impact public opinion of a physician’s practice. The world of retail products and services is no stranger to consumer reviews. Since the early 20th century, organizations such as Consumer Reports have been testing and reviewing retail products and services and making findings available to the general public. More recently, websites such as Yelp, Google, Facebook, and Twitter allowed consumers to offer opinions on everything from restaurants and beauty salons to mechanics and accountants. It is, 836 Topics in Practice Management
therefore, not surprising that patients and their families are also shopping the medical market of physicians and offering personal experiences for others to read. A 2014 study from the Journal of the American Medical Association surveyed a nationally representative sample of the US population about their knowledge and use of online physician rating websites in the selection of a physician. Fifty-nine percent of respondents reported that physician rating websites were either “somewhat important” (40%) or “very important” (19%) when choosing a doctor. The study also noted that 35% had selected a physician based on positive internet reviews. Conversely, 37% of those surveyed had avoided a physician because of a negative review.29 According to a 2010 study by Lagu et al,30 33 different physician rating websites were identifiable via a simple Google search. A search performed for a random sample of 300 Boston-area physicians showed that the majority of reviews (88%) were positive, with only 6% being neutral and 6% negative. Of note, 70% of the physicians searched for had no online reviews available.30 Similarly, another study from 2012 of physician ratings on ratemd.com and yelp.com showed that the majority of online physician reviews (63%) were positive and recommended the physician to others.31 Although these websites have not been scientifically validated, it is likely that their importance will only grow as younger generations of social media-savvy patients age and increasingly seek health-care services. Future patients and employers can easily access these publicly available sites making it increasingly important for physicians to proactively monitor and manage their online presence. Performing regular Google searches and monitoring online physician rating site comments are important to maintaining a positive public perception of one’s practice. Engaging in rather than ignoring the online health-care consumer community is critical. Through the creation of professional practice websites, thoughtful responses to patient comments, and active engagement through social media, the 21st-century physician can maintain control of his or her “online story” rather than remain solely at the mercy of the digital opinion of others.32,33
Future Impact of Patient Satisfaction Although opinion on the correlation of patient satisfaction scores with clinical outcomes remains divided, it seems highly likely that ratings of patient experience will only continue to grow in importance for the practicing physician. Whether through nationally sponsored
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surveys or online physician rating websites, patients and their families are increasingly eager to access physician quality and patient satisfaction ratings to aid in the selection of a new care provider. As patient satisfaction becomes more deeply entrenched into physician reimbursement and credentialing, it is important for the provider to remain abreast of the continually evolving health-care landscape. The data provided by patient experience surveys provides an opportunity for practice improvement but the strategy for improving survey ratings will require an individualized approach for each practice, presenting a challenge in terms of time and resource allocation. We expect the requirements for both board certification and reimbursement incentives to continue to evolve over time. Overall, it seems likely that, at least for the foreseeable future, patient experience will remain an important factor in pulmonary inpatient and outpatient practice management.
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Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/ organizations whose products or services may be discussed in this article.
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