Winners Vs. Losers: Are the Patients the Real Winners in this Game?

Juan S. Barajas-Gamboa

It cannot be denied that healthcare services have become an attractive business for any party involved, whether it be government, insurance companies, hospitals and doctors, to look out for their own interest and leave aside the real priority of this system – the patients’ healthcare and welfare.¹

Recent proposed changes in the health system (i.e. healthcare reform) have commanded the attention of all people involved. If nothing else, it has provided an avenue in which each detail can be scrutinized and assessed. And, ultimately, it can be used to optimize the balance of clinical outcomes with resource requirements.

As expected, each guild has its own theories and proposals for improving the delivery of care. However, coming to a consensus will be a difficult task given the economic interests at stake. It should be obvious that the most important guild affected by the changes is the guild formed by patients.²

From the physician’s point of view, achieving optimal patient care has become more difficult. In part, this is due to how the government has chosen to assess and improve the delivery of healthcare services, which is by implementing patient surveys to assess the quality of care and level of satisfaction. Basically, the government has hired private companies to prepare and distribute these assessments. Based on the results of these surveys, the government will allocate various economic resources. As a strategy to face these measures, hospitals have established annual incentive plans to motivate doctors to get good scores in patient satisfaction surveys, including offering higher salaries and compensations.^2-3

This impasse pushes the system to operate in an inappropriate manner. For example, hospitals and physicians have increased the number of diagnostic tests, surgical interventions, use of medications, and number of hospitalizations with the sole purpose of making their patients happier. By showing more interest in their patients’ diseases, the hospital and physicians expect to get better scores on the surveys. However, this excess of interventions and expenses does not always ensure the best clinical outcomes. Instead, increased monetary investments can directly affect the finances of the health system.^3-4

Currently, 66% of physicians are sheltered under an annual incentive plan; this leads to the idea that "more satisfaction of patients = higher salary.” Many authors consider this to be the silent murderer of the healthcare system since it does not guarantee increased patient satisfaction but it surely guarantees high monetary investment strategies.⁵

There are two key questions to address as a result of the problems generated by the survey results: How reliable are these surveys? Must we, as healthcare providers, modify our daily clinical practice based on these results? To start, I should mention that from my perspective as a physician, I do not agree that wage benefits and salaries of medical staff should be defined based on these results. More importantly, it should not determine the amount of money provided by the government to the health system and as aid to hospitals.⁵

Up to today, many scientific studies have been conducted to determine the impact of these assessments on the quality of the service in terms of clinical outcomes and patient satisfaction. The findings are controversial because some studies support the hypothesis that there is direct relationship between the scores of the surveys and the quality of healthcare services provided to patients. However, other studies have shown opposite results. There are some key points to be considered to reach a more objective conclusion regarding the implementation of these evaluation systems for medical staff and hospitals.^2-4

There are many factors involved in each patient's experience that can affect the general opinion on the quality of his or her medical treatment and how satisfied he or she was with the treatment. Many observers argue that the number of treatments directly correlates with a better perception of the quality of patient care, regardless of the final outcome of the disease. On the other hand, some authors argue that there is a direct relationship between the expected and actual results achieved, thus fulfilling levels of patient expectations.

Based on this relationship, patients judge the effectiveness of physicians and medical staff according to their levels of satisfaction. However, it should be noted that patients receiving a greater number of interventions and treatments do not always get maximum level of satisfaction in spite of all the effort from the physicians and their teams. In fact, better results have been found on surveys when patients are encouraged to take the leadership of their medical treatment. This leads to better clinical outcomes and a reduction of resources used.

Other factors that may influence the assessment outcomes are: the number of events evaluated per patient (since many of them are chronic patients and have different experiences to be evaluated), the number of physicians involved in the patient care (i.e. different specialties working together), the time between medical care, and the evaluation of that care.³

Despite the variety of studies available in this particular area of knowledge, there is no clear definition of patient satisfaction in healthcare. In turn, many authors are concerned with the patients’ lack of medical knowledge. Therefore, if they receive negative patient comments, they cannot adequately judge and modify their medical practice.

In conclusion, the government must design healthcare reform strategies with all parties in mind. The ultimate goal of these strategies should be to safeguard the healthcare and welfare of patients, not to implement controversial evaluation systems that create conflicts within the system and ultimately lead to detrimental changes in physicians’ clinical practices.

References

1. Fu AZ, Wang N. Healthcare expenditures and patient satisfaction: cost and quality from the consumer's perspective in the US. Curr Med Res Opin. 2008 May;24(5):1385-94. doi: 10.1185/030079908X291994 . Epub 2008 Apr 2.
2. Fenton JJ, Jerant AF, Bertakis KD et al. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012 Mar 12;172(5):405-11. doi: 10.1001/archinternmed.2011.1662. Epub 2012 Feb 13.
3. Manary MP, Boulding W, Staelin R et al. The patient experience and health outcomes. N Engl J Med. 2013 Jan 17;368(3):201-3. doi: 10.1056/NEJMp1211775. Epub 2012 Dec 26.
4. Jha AK, Orav EJ, Zheng J, et al. Patients' perception of hospital care in the United States. N Engl J Med. 2008 Oct 30;359(18):1921-31. doi: 10.1056/NEJMsa0804116.
5. Falkenberg K. Why Rating Your Doctor Is Bad For Your Health.Forbes. (2013, Jan 21). Retrieved from http://www.forbes.com/sites/kaifalkenberg/2013/01/02/why-rating-your-doctor-is-bad-for-your-health

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