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Should Patients Join the Pay-for-Performance Circus?

There was an extremely popular game show where several times each episode the emcee would shout out, "Survey Said!". Of course, this was just a game, not real life.  Now, several times each week I am asked to respond to surveys.  They pop up uninvited on the internet and are often veiled advertisements for products and services. They are on the back of receipts from coffee houses and doughnut shops.  Is it worth 10 minutes of my time clicking through the doughnut survey for either a free chocolate frosted doughnut or the chance to be entered into the grand prize drawing months later?  Hotels I stay at routinely follow-up with e-mail surveys for my feedback.  I suspect most folks delete these instantly, which skews the customer base to those who do respond. (Remember, disatisfied folks are often more motivated to give feedback than the rest of us are.) How often do we call a restaurant, a retail store, a bank or even a doctor's office to offer hosannas about great service?

Medicare recently released fascinating patient-survey data that raises interesting issues. In over 120 hospitals, patients rated the hospitals very highly, despite high death rates for heart disease and pneumonia. So, who do we believe here, the patients or the death rates?  I wonder if the patients' survey results were more optimistic since only the live ones were available to complete them.

Surveys are now serious bu$ine$$.  Reimbursement for hospitals and physicians will be influenced in either direction by patient satisfaction results.  But, are patients equipped to measure medical quality?  The discrepancy between the Medicare patient survey results and actual medical outcomes suggest that they are not the right tools for this task.  How can we expect ordinary folks to understand and rate medical quality when experts are confounded by the same mission?

Surely, there are important aspects of the medical experience that patients can evaluate.

  • On-time performance
  • Cleanliness of the facilities
  • Courtesy of the staff
  • Compassion and bedside manners
  • Responsiveness to billing issues
  • Ease of making appointments
  • Timely communications
  • Ease of reaching a living, breathing human being for a question or concern
But, while the above items are significant, are they true measurements of medical quality in the conventional sense?  Is the definition of medical quality being broadened simply to encompass measurable events?

Patients are being recruited under the Big Top, aka as the Pay-for-Performance Circus.  But, should patient surveys really count?  Or, do they count simply because their results are so easy to count?  Despite the dissenting arguments against P4P advanced on the Whistleblower, a must-read blog for health care thought leaders across the country, patient surveys will be folded into the expanding hydra of P4P programs. These programs won't measure true medical quality, at least in their current forms.  But, what a performance they will be.  The curtain will rise as the Secretary of Health and Human Services approaches the podium and shouts out, Survey Said!  What a Family Feud this will be.


  1. Your post brings up an extremely important point- Are patients truly equipped to evaluate their medical care?

    Patient expectations must also be accounted for. A patient may respond with negative feedback if they are denied antibiotics, pain medication, or admission to the hospital-- regardless of whether that treatment is medically indicated.

    Another issue may be the "Dr. House effect". Patients may rate their experience based on the friendliness of staff, rather than the medical expertise. Patients may be unaware of the behind-the-scenes coordination of medical care, and rate their experience based on who they come in contact with, rather than the management of their case.

    Surveys are the easiest, yet the least reliable of program evaluation media. How reliable will the P4P data be?

  2. Someone has said (I think it was Bob Wachter, but I'm not positive), "If something is easily measurable, it will be measured, no matter how irrelevant the measurement might be to quality control issues".

    At one of my hospitals, I frequently see graphs on how successful the nursing staff was on getting the doctors to sign and date their H&Ps.

    I've never seen a graph on cecal intubation success rates, or average time of scope withdrawal, or adenoma detection rates, or anything that might truly reflect on the quality of care. We are very good and signing and dating our H&Ps, though.

    Patient feedback is important. It isn't the only piece of the puzzle, but it's a darned important piece. Whether the surveys are accurate are another matter.

    Michael, I've taken up your challenge and brought a zombie blog back to life:

  3. Well, Andrew, now we know your first name. Incidentally, I've contacted 'Leisure Guy' who promises to return soon. I wish your rejuvenated blog every success and invite readers there.

    @LAM, as to how reliable P4P will be? Search this blog for 'pay for performance' and get ready for a hurricane of hot air that may incinerate you!

  4. I believe we are the midst of what I call the Medical Reformation. Prior to Luther's 95 theses and the development of the printing press, the Catholic Church held tightly to the belief that ordinary people were not capable of reading their own bibles or understanding the concepts related to their fates in the hereafter.

    Similarly, the perspective that patients are inherently not in the position to understand know what is in their best medical interests smacks of the same sort of paternalism. Yes, the surveys are VERY imperfect and measure some things which may or may not be relevant to what we as physicians view as important.

    Remember, we are in a service industry and it should be viewed as a non-starter that the perspectives of those delivering the service should be held as more important as those receiving the service. That we query patients regarding their needs are met should be an integral part of what we do. If we haven't developed the right tools to do so is more a reflection of our shortcoming than anyone else.

  5. @MC, thanks for the comment. While I agree that patients' views and feedback are valuable, I am skeptical that this is the right tool for assessing medical quality, which even experts cannot easily define and measure. I feel that the 'Quality Police' are measuring us like tailors, which will generate data that will be used to grade our quality. I don't accept the assumptions that what they can measure really counts.


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