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Patient empowerment: Next step in accountable care

January 30th, 2013

by Kent Bottles

Recent articles highlight challenges with holding providers accountable for the care they deliver. One of the major thrusts of efforts to transform the American healthcare delivery system has been to become more patient-centered and to allow patients to provide feedback that matters.

Emblematic of this is the emphasis on patient involvement in the final rules for the Shared Savings Program accountable care organizations (ACO).

Echoing former Centers for Medicare & Medicaid Services Director Don Berwick's plea on the behalf of patients ("Nothing about us without us"), the ACO final rules emphasize patient engagement in governance, quality improvement and the individual doctor/patient interaction.


Michael Millenson's white paper provides a summary of the patient empowerment movement.

The development of the patient activation measure (PAM) and the Center for Advancing Health's 43 engagement behaviors has allowed us to study patient-centeredness with more specificity. Studies have shown that activated patients are less likely to choose surgical interventions, have better functional status and satisfaction, are more likely to perform self-management behaviors, and report higher medication adherence rates.

Healthcare policy experts and payers have embraced the argument outlined above, and patients' reports of their satisfaction with both physicians and hospitals have increasingly been used to calculate financial rewards.

For instance, a recent Hay Group survey of 182 healthcare groups documented that about 60 percent of physicians are paid under an incentive plan, 66 percent of which incorporate patient satisfaction scores.

But critics of such an approach have become more vocal, and their objections can be classified into three major types:

1. Patient feedback should not be tied to compensation because patients do not know enough about medical science to give meaningful feedback.

2. Patient experience measures may be confounded by factors that are not directly associated with the quality of care delivered.

3. Patient experience scores may reflect fulfillment of patients' a prior desires, such as wanting a drug regardless of evidence-based medical benefit.

A Forbes article earlier this month captured physician anger with being judged by patient satisfaction scores:

"The current system might just kill you. Many doctors, in order to get high ratings (and a higher salary), overprescribe and overtest, just to 'satisfy' patients, who probably aren't qualified to judge their care. And there's a financial cost, as flawed survey methods and the decisions they induce, produce billions more in waste. It's a case of good intentions gone badly awry--and it's only getting worse."

However, a New England Journal of Medicine article this month disputed the Forbes analysis. The North Carolina academics concluded:

"Both theory and the available evidence suggest such measures are robust, distinctive indicators of health care quality. Therefore, debate should center not on whether patients can provide meaningful quality measures but on how to improve patient experiences by focusing on activities (such as care coordination and patient engagement) found to be associated with both satisfaction and outcomes, evaluate the new care-delivery models on patients’ experiences and outcomes, develop robust measurement approaches that provide timely and actionable information to facilitate organizational change, and improve data-collection methods and procedures to provide fair and accurate assessments of individual providers."

My guess is that the proponents of using patient satisfaction scores to hold providers accountable will in the end prevail. However, the level of dissatisfaction of some physicians with patient satisfaction surveys documented in the Forbes article highlights how important changing physician culture will be in successfully reforming the delivery system and ensuring healthy and satisfied patients.

Dr. Kent Bottles is a Senior Fellow at the Thomas Jefferson University School of Population Health.


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