Patient Satisfaction and Quality of Care: Are They Linked?

Reining in the Business Model

Medscape: What you think about the increasing practice of linking physician reimbursement to patient satisfaction scores instead? Is a "business model approach" to healthcare appropriate to improve patient satisfaction (ie, meet customer expectations)?

Dr. Fenton: It's appropriate, as long as it is not overemphasized. I have to give my bias as a primary care physician. From my perspective, it isn't wrong to have some degree of incentive tied to whether my patients are happy with the care that they receive from me. But that needs to be balanced by other measures, and an appropriate balance is important. Tying a very large percentage of a primary care physician's income to patient satisfaction would be problematic, because it could skew the physician's priorities and lead some physicians to neglect some of their essential duties as primary care clinicians.

We also don't want physicians to avoid taking care of patients (such as Medicaid patients and those with mental health issues) who are more likely to report dissatisfaction.

Medscape: Recently, there has been interest in tying payment in the primary care setting to performance, as is done in Europe, where there are financial incentives for reducing blood pressure or cholesterol in a certain number of patients. Is that also part of assessing physician performance?

Dr. Fenton: I am supportive of efforts to move away from the awful incentive of fee-for-service reimbursement -- which, in primary care, encourages more and faster visits without attention to technical or interpersonal care quality. I can envision a blended payment scheme that simultaneously rewards volume, technical quality, and patient experience.

But we need to be wise about the perverse incentives that each measure may introduce. If the payment scheme overemphasizes patient satisfaction, particularly maximal satisfaction, then financial incentives may steer some physicians from the hard work of addressing difficult topics with patients, and may lead to more low-value tests or treatments, and physician attempts to avoid difficult-to-satisfy but vulnerable and needy subgroups of patients.

I have a particular soft spot for patients suffering from chronic depression or anxiety, for example. These patients are probably not the easiest to satisfy, but they need continuity of care with a patient, conscientious physician who understands these problems and the possible somatic manifestations of these illnesses. Most primary care physicians can think of patients in their practice who need regular care and benefit from having a regular provider but who are almost impossible to highly satisfy. But we still have an obligation to serve these patients, and reimbursement schemes should be designed so that physicians don't reevaluate their commitment to service.

Medscape: What can physicians do if they are not receiving high satisfaction scores but believe that they are delivering quality care by other measures? Could improvement of communication skills help some physicians improve their scores or ratings?

Dr. Fenton: It depends on how you define "low" satisfaction scores. Physicians consistently scoring at the bottom 20th percentile of CAHPS may be repeatedly making some simple fundamental communication missteps that are causing recurrent problems in their encounters. Those physicians might benefit from simple interventions. A supervisor or a trusted peer should help that doctor identify missteps and ameliorate them. Perhaps it would also be possible to capture some patient encounters on video or audiotape for review with a colleague or consultant.

On the other hand, if a physician's satisfaction scores are in the middle of the bell curve for his or her peers and this physician is doing his or her best to communicate with respect, empathy, and care, then we have no compelling evidence to force that physician to change.

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