I am writing this on 28 June 2012, the day the U.S. Supreme Court upheld most of the provisions of the Affordable Care Act. I shall say a bit about the ACA at the end of the column after addressing an even broader topic into which it fits. That topic is in the title. I have ruminated about this in one way or another for a long time and the progression of my thought follows.
When I was a rotating intern 51 years ago, I was assigned to a series of inpatient units and cared for mostly medical patients. One of the attending internists (let's call him Dr. Feelgood) had a large practice that consisted mostly of older women. In those days there were no limitations of the hospital length of stay by health insurers and these patients often were hospitalized for a week or more, so there were always one or two of them in our unit alone.
Dr. Feelgood's patients had vague complaints that included fatigue, malaise, nervousness, depression, and/or some gastrointestinal upset or irregularity; in a generation earlier, this was diagnosed as “the vapours.” Dr. Feelgood routinely ordered the intramuscular injection of vitamin B-12 daily for many of his patients. None of the patients had vitamin B-12 deficiency or pernicious anemia. I soon realized that he was administering a placebo that was probably more convincing when given by a painful injection than by tablet. His patients loved and even revered him. His bedside manner was masterful and he took the time to listen to his patients' every complaint. But we never found a diagnosis that warranted either hospitalization or B-12 injections.
I was confused by what I saw. His therapy was physically harmless but may have provided some psychological relief to his patients; if so, it was because they had faith in him and trusted his judgment. Some of the staff tacitly approved this sort of therapy as using psychosomatic medicine for treating psychosomatic illnesses. But most did not and it certainly didn't feel right to my house staff colleagues or me.
This was the first of many instances I observed over the years of poor-quality care in patients who were very satisfied with their physician and the care he provided.
Put starkly, is our primary focus on satisfying the patient or providing the highest quality of medical care? Of course we, and our patients, want both and we strive for that happy outcome. But it is a common error to assume that a satisfied patient is de facto receiving high-quality medical care.
Surveys like Press-Ganey are often advertised by hospitals with good scores as proof of the high quality of medical care that they provide. Press-Ganey describes its services as “driving performance excellence.” But Press-Ganey and all the other patient satisfaction surveys do not measure the quality of medical care at all. Convenient parking, short waiting times, and courteous service are very desirable and leave patients with a positive feeling, but they are not indicators of high-quality medical care.
In fact, there is objective evidence from several sources that the opposite often applies, such as a recent publication in the Archives of Internal Medicine (2012;172:405–411): “The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures and Mortality,” by Joshua J. Fenton et al.
The authors conducted a prospective cohort study of 51,946 adult respondents to the 2000–2007 national Medical Expenditure Panel Survey. Five items from the study were used to estimate the adjusted associations of year-one patient satisfaction with year-two outcomes in health care utilization (e.g. emergency room visits and inpatient admissions), year-two expenditures (total and for prescription drugs), and mortality during a mean follow-up period of 3.9 years.
Adjustments were made for socio-demographics, insurance status, availability of a usual source of care, chronic disease burden, health status, and health care utilization and expenditures in year one. Respondents in the highest patient satisfaction quartile compared with the lowest satisfaction quartile had significantly higher odds of an inpatient admission, significantly greater total expenditures and prescription drug expenditures, and higher mortality. The higher satisfaction group had fewer emergency room visits.
Other publications, some cited in this same paper, have shown that patient satisfaction had no association with the medical quality of care in vulnerable geriatric populations. Another showed that when patients requested discretionary services that are of little or no medical benefit and physicians accede to these requests, this was associated with greater patient satisfaction. Physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services, such as advanced imaging for low back pain.
Health care intensity varies widely across the country. In three chronic illness categories, a Medicare study showed that greater health care intensity was associated with greater patient satisfaction, but also with higher mortality and without improvement in the quality of care.
So the link between high patient satisfaction and the quality of care is tenuous at best and is often associated with a poorer quality of medical care, higher cost, and worse outcomes.
High patient satisfaction is very desirable for doctors as well as patients. But the focus should primarily be on high-quality medical care first, including appropriate and useful diagnostics and therapy, attention to the cost of care, and high standards for the process and outcomes of care. ASCO is a leader in increasing the focus on quality care with its QOPI program and its recent recommendations, with the American Board of Internal Medicine, of “Choosing Wisely: The Five Things Physicians and Patients Should Question.”
The Affordable Care Act has some provisions for improving the quality of care, for which many organizations have already been preparing. And one cannot give high quality of care if the patient has no access to care; the ACA addresses that issue. There are some parts of the ACA that are problematic, but from my point of view, improving quality and access serves our patients and potential patients well.