Thursday, June 30, 2016

Is Linking Patient Satisfaction to Reimbursement Feasible?

In 2006, the Centers for Medicare and Medicaid (CMS) instituted Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a survey which serves as a standard measure of patient satisfaction.  HCAHPS became mandatory in 2007 for facilities who receive Inpatient Prospective Payment System (IPPS) funds and wished to be eligible for full payment.  This was further solidified when the Hospital Value Purchasing Program (VBP) was instituted as part of the Patient Protection and Affordable Care Act (PPACA) in October, 2012.  This affects Medicare payments; however, it is projected to be applied to Medicaid and the Children’s Health Insurance Program shortly—the process was piloted in 2015.

The survey is administered usually anytime from 48 hours to 42 calendar days post discharge.  That is a large window and distance can skew results both positively and negatively.  The most honest response is likely to occur shortly after discharge. If a patient becomes incapacitated and goes into long-term care, the family members will complete the survey. 

HCAHPS consists of 32 questions that ask how often a patient experienced a critical aspect of hospital care. The questions from the March 2016 version are as follows:

Scale: Never Sometimes Usually Always
During this hospital stay:
1.  How often did nurses treat you with courtesy and respect?
2.  How often did the nurses listen carefully to you?
3.  How often did nurses explain things in a way you could understand?
4.  After you pressed the call button how often did you get help as soon as you wanted?

Questions 5-7 are questions 1-2 repeated asking about the physician in lieu of the nurse.

8.  How often were your room and bathrooms kept clean?
9.  During this hospital stay how often was the area around your room quiet at night?
10-11.  If a bedpan was used, how often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?
12-13.  If pain medicine was administered, how often was your pain well controlled?
14.  How often did the hospital staff do everything they could do to help you with your pain?
15-16. If new medicine was administered, how often did the hospital staff tell you what the medicine was for?
17.  How often did hospital staff describe possible side effects in a way you could understand?

Questions 18-20 are demographic in nature and yes/no questions regarding written discharge info.

21.  Patients are requested to rank the hospital stay from 1-10 with zero being the worse possible stay.

22-32 Demographic questions with the most important being would the patient recommend the hospital to others.

In October, 2012 CMS began withholding 1% of hospital’s Medicare reimbursement in case patient satisfaction scores did not meet thresholds.   By 2018 a total of 2% will be withheld. Through a complicated set of measures and calculations, reimbursement incentives are calculated.  The calculations can be found at
This ultimately results in up to 30% of a facility’s reimbursement being tied to patient satisfaction which is measured by the HCAPHS.  If the patient does not answer these questions positively, reimbursement will be significantly affected. Hospitals nationally will be compared with one another; thresholds will be set for each reporting period based on the 50th percentile and the high performers nationally.  In areas where most hospitals do very well, small changes can have a very significant impact and result in reduced reimbursement.

Most likely everyone can agree patient satisfaction is important.  But does patient satisfaction with care equate to quality of care?  A patient can be very happy with his hospital stay, yet he may have not received the best clinical medical care.  What a patient wants is not always what he/she truly needs.

There are a plethora of confounding variables surrounding this issue.  These issues include health literacy, language barriers, but most importantly perceptions. If you look at the rating system (Always, Usually, Sometimes, Never) and questions 1-2 and 5-7 about nurses and physicians treating the patient with courtesy and listening, there are potential perception issues.  How much is usually?  Is it 7 out of 10 interactions?  It may in fact be to the ones who created the survey, but is it to the patients?  A patient could interpret a few instances within 100 interactions as either always, usually or sometimes depending on the patient’s perspective that particular day.  If a nurse is in a room talking with Patient A when suddenly she is called away to her patient down the hall by a colleague, the patient she was talking to may perceive this as a negative interaction and mark the nurse down on listening.  Yet she might have been called away because a patient coded; because of HIPAA, Patient A has no right to know this.  The nurse can apologize for being called away for an emergency, but Patient A may view her emergency as more important than Patient B’s even if she just wanted someone to talk to and Patient B was dying. 

Let’s look at question 4.  The key to this question is “as soon as you wanted it.”  There is a big difference between a patient who rings the call button to have someone close the drapes compared to someone that rings it in an emergency.  Yet some patients expect immediate response to their every request as those who have worked in health care can attest. 

The question surrounding pain management is particularly problematic when considering patient perceptions.  Pain is real and we all feel it differently; however, those who are drug-seekers and drug abusers may likely note their pain was never controlled because they want higher level of narcotics.  Yet these patients may be included in sampling if they do not have a psychiatric diagnosis.

In general, it is very likely a facility can have numerous patients in their population that are dissatisfied because necessary medical treatment and intervention was outside a patient’s comfort zone.  Medical procedures can hurt, medicine tastes bad and may not work as expected.  Health care is an art and not a science because each individual is different.  Patients who just had surgery do not want to get out of bed right afterward, but this yields better outcomes and recovery even if satisfaction is decreased. A patient who is morbidly obese may consider true information delivered in a polite and respectful manner (such nutrition and weight counseling, or cautionary information about increased mortality rates) as bullying and this will impact how the patient may rate satisfaction with the facility and caregivers.  Yet this was truly the right thing to do for the patient even if he/she does not view it as such.  Advice that conflicts with a patient’s desires and wants is not always viewed positively by a patient.

Alexandra Robbin on April 17, 2015 reported in the Atlantic that some hospitals some hospitals have gone to extreme measures to get good patient satisfaction scores.  These includes things as valet parking, custom meals, VIP lounges, and a 5-star hotel feel.  However, this will only drive up the cost of health care ultimately.  County hospitals that serve large populations of undocumented aliens (such as in my home state of Texas) and those without health insurance are already losing uncompensated care reimbursement under the PPACA.  Yet they still do this compensated care. These facilities usually have a large population of Medicare and Medicaid patients.  This patient satisfaction requirement will cause these facilities to once again tighten their purse strings when there is little left to cut which could, in fact, negatively impact quality of care even more.

Patient satisfaction is important. Patients should be treated respectfully and should have their conditions and care explained to them in a way they can understand.  However, for guidance and perspective on such incentivized systems we can look to our secondary education system.  Since No Child Left Behind was enacted which has an incentivized payment for performance system, the U.S. has continued to lose intellectual ground compared with other countries in its secondary schools.  The poor performing schools with low scores were penalized and were given less funding while high performing schools were rewarded with additional funding.  The poor schools got poorer and the educational gap continued to widen.  Disparity already exists in health care.  Time will only tell if this incentivized system will widen the gaps.

Submitted by Dr.  Colleen Halupa, Adjunct Faculty, Saint Joseph’s College

Monday, June 27, 2016

Value Based Purchasing/Value Based Payment (VBP)

VBP has had more than one evident goal since its inception. There continues to be speculation concerning the degree to which one or more dominate the impetus for the model’s emergence. For example, in 2003, CMS began to pilot a hospital VBP model, which has since also been utilized by private insurers to discourage “inappropriate, unnecessary, and costly care” (Sultz and Young, 2014, p. 152). Two parameters, i.e. “clinical processes of care measures and “patient experience of care measures” (p. 152) as modifiers to hospital reimbursement. Hospitals performing well would receive financial benefit, while the reverse would be true for poorly performing hospitals (Advisory Board, 2015).
A “Triple Aim” for the VBP model is captured with the following introductory statement in the VBP publication from CMS, from Sylvia Mathews Burwell, Secretary of the U.S. Department of Health and Human Services: “Whether you are a patient, a provider, a business, a health plan, or a taxpayer, it is in our common interest to build a health care system that delivers better care, spends health care dollars more wisely and results in healthier people (CMS, 2015, p. 1).” Similar and yet somewhat different are the Institute for Healthcare Improvement’s Triple Aim elements of: population health, per capita cost and the patient experience (Institute for Healthcare Improvement, 2016). Of interest, that while the patient experience is not specifically mentioned with the HHS statement, it is prominent in the VBP model.

In addition to quantity of care, other measures include: “The quality of care provided to Medicare patients; How closely best clinical practices are followed…How well hospitals enhance patients’ experiences of care during hospital stays. How well they perform on each measure; or How much they improve their performance on each measure compared to their performance during a baseline period” (CMS, 2015, p. 1).
For 2016, the “domains” include: clinical process of care, patient experience of care, outcome, efficiency (p. 2).  These differ somewhat through 2018. For a fuller description please see the entire CMS document listed in the reference list.
In reading the elements contained within process of care, it appears they would be included within the concept of evidence-based clinical guidelines. The application of evidence based medicine is an attempt to standardize care, with the expectation that by doing so, there will be less variation in patient outcomes (Sultz and Young, 2014, pp 228-229). Outcomes can refer to what effects did providers have on their patients. Did they get better; did they get worse; were they cured; did they die; how did you change their quality of life; did you keep them healthy or make them healthier (Sultz and Young, (2014).
The measure for efficiency with the CMS VBP model is “Medicare Spending per Beneficiary” (CMS, 2015, p. 4). Of interest, the denominator is not cost divided by outcome or by process.
            Patient experience is measured by HCAHPS scores (CMS, 2015). The question arises as to how does the patient experience fit in with the other domains, and to what extent is it congruent with better care, healthier populations, greater efficiency, providing the right care or obtaining the best outcomes?
To what extent has VBP been successful relative to outcomes: Researchers, evaluating 100% Medicare inpatient claims data from 2008 through 2013, for patients admitted with “acute myocardial infarction, congestive heart failure, and pneumonia” concluded:  “Evidence that HVBP has led to lower mortality rates is lacking. Nations considering similar pay for performance programs may want to consider alternative models to achieve improved patient outcomes” (Figueroa et al, 2016).
In its first three years of implementation, GAO reported in a report from late 2015: “Medicare's Hospital Value-Based Purchasing Program has not yet led to increases in care quality overall… even before the program began in October 2012, hospitals had been improving in how consistently they followed basic clinical guidelines… improvement continued but did not increase with the advent of the financial incentives. The same was true for patient ratings, on such items as the quality of communication from doctors and nurses, and for mortality rates for heart attack patients. Heart failure and pneumonia death rates stayed roughly the same” (Rau, 2015). GAO further concluded “Our analysis found no apparent shift in quality measure trends during the initial years of the program, but such shifts could emerge over time as the program implements planned changes (Rao, 2015).”
The principles of VBP have become more pervasive in their application to more than just Medicare and to more than just hospitals, but have been adopted by many insurers and now apply to many types of providers. Miller (n.d.) provides an extensive analysis of VBP in terms of evident issues and makes suggestions for how these issues could be resolved. Below are some “cases” illustrative of some of these issues:
Issue: Physicians are penalized for caring for complex, high risk cases.
Case: A patient with diabetes and hypertension has been non-compliant with medication usage and diet. The physician practices evidence-based medicine, ordering all the “right tests,” all the
“right medication,” all the right “education and counseling.” The physician is employed by a health network and some part of “pay,” is linked to “productivity.” While the physician has practiced evidence-based medicine, the patient has poor outcomes. The patient continues to be unhappy with the care, because he does not like the restrictions the physician is trying to impose on his diet. Because patients such as this require an extensive time commitment from the physician, taking on such patients severely hamper the physician’s ability to meet productivity targets for enhanced “pay.” What is the likely reimbursement “penalty” because of likely poor outcomes and patient dissatisfaction? How likely is the practice to continue to make such high risk patients a major part of its care, knowing the likely reimbursement penalties?
Advisory Board Company (October 6, 2015). One of Medicare's big value-based programs has delivered little value so far, GAO says
Department of Health and Human Services, Centers for Medicare & Medicaid Services. (September 2015). Hospital value-based purchasing. Retrieved from
Figueroa,J., Tsugawa, Y.,  Zheng, J.,  Orav, J., &  Jha, J. (May, 9, 2016).   Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: Observational study. BMJ 353 doi: Retrieved from
Institute for Healthcare Improvement (2016). IHI triple aim initiative. Retrieved from
Miller, H. (n.d.). Measuring and assigning accountability for healthcare spending: Fair and effective ways to analyze the drivers of healthcare costs and transition to value-based payment. Retrieved from
Rao, J. (October, 2, 2015). Hospital care unaffected by quality Payments, GAO finds. Kaiser Health News. Retrieved from
Sultz, H., & Young, K. (2014). Health care USA (8th ed.). Burlington, MA: Jones and Bartlett.

Submitted by Dr. Walter Markowitz, Adjunct Faculty, Saint Joseph's College