Patient Satisfaction: Is It Overrated?

Amanda Loudin

January 19, 2022

Ask doctors about patient surveys and you'll likely draw a shrug or an eye roll. Some physicians and hospital administrators find them useful, while others find them flawed.

Greg Hood, MD, internist in Lexington, Kentucky, said: "The surveys may be equally applied as attempts to praise a worthy or popular provider as they may be an angry attempt at revenge or spite as to represent a true alert to a concerning practice of behavior."

Patient satisfaction surveys, including the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS); Healthgrades; Press Ganey patient satisfactions surveys; and other facility-designed or third-party-designed surveys have been around for decades now. Some are maintained within a medical system, while others reach search engines like Google or Yahoo, where future patients can easily put their hands on them. Still others are presented in the form of free-flowing online reviews.

The merits of patient surveys — and physician sentiments toward them — may vary, but they remain an integral part of the patient experience at most hospitals, large practices, and urgent care centers.

The Problems With Patient Surveys

Much of the debate surrounding patient surveys involves their makeup and distribution. "Often by the time a patient receives a survey, they can't remember that far back," said Jeffrey Segal, MD, CEO and founder of New Jersey–based Medical Justice. "The questions are sometimes dated, and the multiple-choice format isn't as useful as free commentary."

Segal would rather see surveys at the point of service, while the visit is fresh in a patient's mind, allowing for free narrative feedback. "That would make the information more digestible and easier to act on," he said. "For these reasons, the likelihood of finding a doctor who truly likes patient surveys is very low."

Some doctors worry that the survey feedback can be misused, as well.

This is particularly relevant in today's charged pandemic atmosphere. One physician, who wished to remain anonymous, offered this example: "You try to convince someone to get the COVID vaccine, which would be good for the population, and they argue with you about it," he said. "They write a bad review and give it to your customer satisfaction department, and it adversely affects your quality bonus."

Segal said that while he doesn't know how much the pandemic is affecting HCAHPS survey results, "it's definitely impacting the reviews you see on sites like Google."

There can be upsides to this, he adds. "You see the difference in treatment philosophies on these sites," he said. "In the case of mask mandates, for instance, if a patient is unhappy with that and writes about it online, it can telegraph the message of who is welcome and who is not in a particular practice. That's not a bad thing, and patients can know what to expect from various practices."

Beyond the pandemic, however, there is also evidence that sometimes, surveys can follow an inherent bias. An Indiana Public Health System survey of scores collected revealed "a risk of bias toward women and underrepresented physicians."

The survey found that median and mean of scores for female and racially underrepresented physicians were lower for both groups. The concern, the survey stated, was that potential biases might lead to pay inequities through differences in financial incentives. The authors concluded that "because hospitals have identified patient experience as a potential source of competitive advantage, such actions can create perverse and harmful incentives to elicit positive survey responses."

It added that "Hospital CAHPS is not suitable for evaluating or incentivizing individuals or groups within a hospital, as it is meant to assess the entire hospital experience and culture of patient centeredness."

Perhaps the worst potential misuse of surveys, Hood said, is when an administrator or "aspirational climber" weaponizes the results. "I have seen more than one quality physician who provided superb patient-centric care become the target of a drive to hurt their livelihoods and careers," he said. "Whether it was because they were more focused on the needs and best value, conscientious care for their patient instead of the self-interests of the machine — or not — some have been destroyed in the process."

What's Good About Patient Surveys

While many physicians have negative views of patient surveys, there are still plenty of advocates for them. Bill Wuff, MD, CEO of Central Ohio Primary Care, said that surveys have proven valuable for his facilities. "We don't use HCAHPS surveys, but two other types," he explained.

The first, a Medicare population net promoter score, allows patients to rank the likelihood of recommending the offices to a friend or family member. A score below 6 means the patient is a detractor, whereas a 9 or 10 makes them a promoter. Taking the promoter scores and subtracting the detractor scores, then, gives the system an overall number.

Additionally, regular patients to the Central Ohio practice receive surveys several times a year after their visits. "Any patient who rates us at a 1, 2, or 3 out of 5 gets a phone call," Wuff said. "Our patient relations reps ask what went wrong and what we could have done better."

When patients give their doctors scores of a 4 or a 5, they can leave additional comments, which are shared with the physicians. Over the past 5 years of using surveys, the number of responses has grown, as has the practice's overall score. "We started with only 2250 reviews our first year, and over this past year, we're at 29,000," Wuff said. "Our score began at a 3.9 overall, and now we're at a 4.9."

Wuff said the most effective use of these scores is allowing prospective patients to see them online. "They depend on ratings when choosing a new doctor," he said. "How we are perceived by patients is important, and it allows us to make improvements."

He added that the simplistic net promoter score is an asset to senior patients, who sometimes find more complicated scoring systems difficult to decipher.

How do the doctors at Central Ohio feel about the surveys? "Over time they have come to be more accepting," Wuff said. "Initially, we weren't surprised by the physicians who received high scores," he said. "We've seen those with lower scores work to improve them. Doctors appreciate the proactive nature of our surveys."

There's also value in using the surveys to measure how doctors are feeling themselves, adds Wuff, especially throughout the pandemic. "When some of our net promoter scores went down, it spoke to the decline in the doctor's overall well-being," he explains. "We developed a well-being program for our physicians as a consequence."

Healthcare attorney Heather Mace, of Fennemore Law in Arizona, said, "Surveys have underscored the issues of physician burnout and helped determine how popular and widespread methods like telehealth have become. COVID data has also helped to inform public policy and to show when waves of COVID variants may hit certain communities. This can help physicians and healthcare groups prepare for such events and spread resources accordingly."

On the whole, said Mace, physician surveys offer valuable information to doctors. "Physician surveys and patient surveys still yield a lot of useful information," she said.

"First, they allow physicians who are not on the board of national organizations to have a voice in a range of matters, including but not limited to payment issues, best practices, etc. This can help advocacy groups improve their stances, inform government decisions, show if healthcare reforms are working or not, and/or lead to better patient outcomes."

Making Peace With Patient Surveys

Whether a physician views patient surveys in a positive or negative light — or somewhere in between — the reality is that they are part and parcel of practicing medicine today. For his part, Wuff doesn't see them as a dilemma for most physicians.

"The most significant dilemma might be if a score is reflective of the overall staff rather than the actual treatment," he said. "We help the doctors, and their offices address that if it's an issue."

Segal said that physicians would do well to pay more attention to online reviews as opposed to surveys like HCHAPS. "Statistics have some value, but you can get a much better sense of how a patient feels by their narrative reviews," he said. "That gives you the information you need to solve a problem if one exists."

Ultimately, he said, there may be more online reviews available than other types of boiler plate surveys. "Patients just don't use them very much," he said. "From a physician's perspective, online reviews carry more weight."

Hood adds that all feedback should be taken with a grain of salt. "The flaws in both patient perceptions of quality of care and the metrics by which attempts are made to assess them have been enumerated in many studies over the last 30-plus years," he said. "Certainly, there are value (VALUABLE?) and honest reviews by patients, with both justifiable praise as well as well as criticisms."

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