Measuring Patient Care in the Age of Value-Based Payments

By Andis Robeznieks

Healthcare’s movement from volume to value-based payments continues forward even as Congress endlessly wrestles with whether it will repeal, replace, or repair the Affordable Care Act. Part of this movement is an increased focus on improving patient engagement, satisfaction, and experience and then linking physicians’ reimbursement to those elements. Trepidation is high, as many physicians also link these developments to an increase in paperwork and data collection along with an increasing loss of control over how they practice.

The legislative vehicle driving this change is the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which, unlike the ACA, was approved with overwhelming bipartisan support (making its repeal unlikely). MACRA was the legislative replacement for the hated Medicare sustainable growth-rate (SGR) physician payment formula. Enacted as part of the Balanced Budget Act of 1997, various Congressional interventions were required to prevent SGR-prescribed pay cuts of 20% or more from kicking in.

The repeal of the SGR caused much relief. But for many doctors who are feeling overwhelmed and on the edge of burnout, having their income linked to Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey scores is the latest “one more thing” to be layered on top of an existing high stack of burdens.

The good news, however, is that physicians and other clinicians are working with their colleagues on how to improve patient experience and adapt to their changing role in medicine. It may be surprising to some, but often it’s older physicians leading the way.

The bad news would be that those who are seeking to ease physician fears have their work cut out for them.

The government has linked improved patient experience with better outcomes — mostly due to increased compliance with treatment regimens. This is particularly the case for heart attack patients and people with chronic conditions like diabetes.

“It is logical that care that is more patient-centered would result in better outcomes”

“It is logical that care that is more patient-centered would result in better outcomes,” Joan Wynn, Ph.D., R.N., wrote last year in the North Carolina Medical Journal. “The literature supports this conclusion.”

A new Health Affairs study, however, downplayed the impact that tying payments to experience scores has had. The authors, researchers at the Harvard School of Public Health who examined multiple patient satisfaction measures between 2008 and 2014, suggested that the payments were too small to motivate change.

The measures covered elements such as communication with doctors and nurses, the responsiveness of staff, pain management, discharge planning, and information about medicines ordered. The researchers noted that patients valued clinicians who exhibited interpersonal skills, effective communication, and responsiveness to their needs.

The researchers found that experience scores increased 6.1 percentage points during the study period, but most of the improvement began before the Centers for Medicare & Medicaid Services linked scores to its Value-Based Purchasing (VBP) program.

“More work is needed to clarify what influences improvement in what these surveys are measuring,” the researchers concluded. “Our study suggests that as value-based payment continues to be promoted, it is critical to ensure that payments are structured in ways that lead to better patient experience.”

While linking pay to survey scores gets people’s attention, it may not always get the results policy makers are looking for, said Liz Boehm, director of research at Vocera, a San Jose, Calif.–based clinical communications company.

“Experience” involves the care patients receive, the process in which care is delivered, and the relationship in which it all takes place, Boehm said. A successful patient experience means the quality of care, patient safety, empathy, and respect were all connected, she added.

Survey measures allow organizations to benchmark how patients perceive the way their care is delivered. But “if you’re ‘teaching to the test,’ you’re missing the mark,” Boehm warned.

“Sometimes the best medical care requires difficult decisions and challenges to change behavior”

“Sometimes the best medical care requires difficult decisions and challenges to change behavior,” Boehm said, which could negatively affect a patient’s opinion of the care being delivered.

Measurement must be developed in a way that physicians are not put in a conflict where they feel they have to reduce the quality of care to boost patient happiness, Boehm added, explaining that pain management is an area where this conflict often manifests itself.

Physician frustration with the current focus on quality and satisfaction measures came through clearly in the 2016 Survey of America’s Physicians: Practice Patterns and Perspectives, which was conducted by the Merritt Hawkins physician recruitment firm on behalf of the Physicians Foundation. Almost 17,240 physicians were surveyed, and more than 10,000 comments were collected along with the survey results.

“Medicine may be a business, but it is a delicate business of caring for human beings at their most vulnerable,” one doctor commented. “Compassionate, evidence-based, patient-centered care matters more than keeping track of metrics and patient satisfaction scores.”

This was a common theme.

“The humanism of doctor/patient relationship is becoming completely corporate and bureaucratic. Numbers matter more than people,” wrote one physician.

“Stop tying patient satisfaction scores to hospital and doctor reimbursements and evaluations,” wrote another. “Many studies have shown that the most satisfied patients are the heaviest users of the healthcare system and actually have worse outcomes.”

The survey asked physicians if any of their compensations was tied to quality metrics such as patient satisfaction, following treatment guidelines, compliance, “citizenship,” or error rates. Almost 43% said yes, 45.1% said no, and 12.1% were unsure.

When asked what percentage of their pay was tied to these metrics, most were on the low end: 51.3% of respondents said zero to 10% of their compensation was quality-metric related, and 25.9% stated that 11% to 20% of their compensation was. Only 3.8% said these metrics determined between 41% to 50% of their pay, and 4.3% said 51% or more of their compensation was quality-metric based.

“Death by a thousand cuts,” one survey respondent wrote. “Every month there is ‘just one more thing’ or ‘It will only take a couple of minutes to comply.’ These ‘one more little things’ now take up most of my time.”

Barbara Balik, RN, EdD, principal of Albuquerque-based Common Fire Healthcare Consulting, noted, however, that survey and quality data have been useful to healthcare’s transformation that began decades ago in the early days of the patient safety movement.

“In the ’90s, we were aware that harm was occurring, but we thought it was episodic and not frequent — then we began collecting data,” Balik said, but this has a downside as well.

“The good thing was that we started measuring patient experience, the bad thing is that we reduced patient experience down to a score”

“The good thing was that we started measuring patient experience,” she said. “The bad thing is that we reduced patient experience down to a score.”

Between 2003 and 2007, Balik held the titles of Executive Vice President, safety and quality systems and Chief Quality Officer at Allina Hospitals and Clinics in Minneapolis. In those roles, she was one of healthcare’s first C-suite level executives to focus on those aspects of care specifically.

“I’ve been in this work for a long time, and when you become aware of what’s going on, you see how they are all connected,” Balik said of patient safety, quality improvement, and patient satisfaction and experience.

The focus on patient satisfaction to patient experience represented a “key shift,” Balik said, explaining that it went from asking patients “What do you think of us?” to just “What do you think?”

“It’s not about the score or questions on the survey, but what does the total (physician/care team-patient-family) partnership look and feel like?” Balik said.

Doctors and nurses often lack training in establishing that partnership. It’s beginning to be taught in some medical and nursing schools, but Balik said it’s not yet where it needs to be.

When hospitalists meet patients, Balik recommends that, instead of giving their medical opinion right away, they first ask “What are you most worried about?”

She said that had been found to save physician time by having fewer nurse callbacks.

For office visits, she recommends that physicians first ask patients “What’s the most important thing for you to talk about today?”

Balik also recommends involving patients and families in the design of new facilities or care-delivery systems.

“When we design without patients and families, we tend to over-design and make it more complex — and more expensive,” she said. “When we design with patients and families, it tends to be simpler and faster.”

Balik recognized that learning how to integrate the new focus on patient experience can be seen as the latest addition to the “constant bombardment” of new responsibilities, but she said there is a payoff in the end.

“When patients get involved, it’s energizing, not energy draining,” she said. “People get a boost.”

For physicians on the verge of burnout, “doing the right thing” brings a lot of professional satisfaction, Balik said.

Patrick Kneeland, MD, an internist with the Hospital Medicine Group at the University of Colorado (Aurora) Hospital, agreed.

Just as Balik was one of the first patient safety officers to hold a C-suite position, Kneeland also has the first-of-its-kind position. He’s the hospital’s medical director for patient and provider experience. In that role, he teaches a four-hour communication course for physicians designed to help transform their practices to meet the demands of the new healthcare environment.

“A big part of what I do is engage physician colleagues about what is ‘patient experience,’” Kneeland said. “As physicians, the brain tends to go directly to the survey scores and ‘Is the patient getting what they want?’ from a transactional experience.”

But while that may have been the case with improving patient satisfaction, patient experience deals with other questions. These include: Were you treated with respect? Did you have the health outcomes you expected? Were you integrated into the treatment plan? Did you feel like you had a voice? Were you kept in the loop? Were you given the information you needed to make good decisions?

Not all physicians get it, Kneeland said, because their training tells them that they are the experts and that patients often don’t know what they need. But patients are the experts in themselves, their health, and their values.

Stressed physicians who can adapt and transform their practices into partnerships with their patients “can reconnect with their professional purpose and resilience,” Kneeland said.

He noted how medical schools attract altruistic students with a sense of purpose. They enter the field with “incredibly high” empathy scores that bottom out after training and then get a huge lift back up after about 25 years in practice. But this doesn’t come from their experience as doctors, Kneeland said. It comes from their experiences as patients.

“Physicians who have had their own healthcare issues and experiences and have been in a hospital bed tend to get it more quickly and come to the table with more empathy behind the subject (of patient experience),” Kneeland said.

Doctors tend to be skeptical of plans for basing compensation on survey and quality scores, Kneeland said, so this is why it’s important for physicians to get involved in shaping surveys and quality measures.

“Physician leadership in this space is absolutely imperative and, ultimately, why my role has been created,” Kneeland said. “We’re not going to improve patient experience unless we address how healthcare professionals are doing their work.”