What is your stance on financial incentives for emergency department Consumer Assessment of Healthcare Providers and Systems (ED-CAHPS) scores?
Click the candidates to read their responses.
Jay Kaplan, MD, FACEP
Robert E. O’Connor, MD, MPH, FACEP
Rebecca Parker, MD, FACEP
Jay Kaplan, MD, FACEP
Director of Service and Operational Excellence, CEP America; Attending Physician, Department of Emergency Medicine, Marin General Hospital; Medical Director, Studer Group
The short answer is “not ready for prime-time.”
The Patient Experience of Care Survey (PECS) (now no longer called ED-CAHPS) is currently in its second draft; it is not going away—it needs to be modified. When the survey was in its initial development, I made an attempt through Art Kellerman, MD, to have input in its design. Despite ACEP sending recommendations to them, I never felt that we had adequate input. At the Leadership and Advocacy Conference in Washington, D.C., this past May, Dr. Patrick Conway, chief medical officer of the Centers for Medicare & Medicaid Services (CMS), spoke to us. When he was finished, I ran after him and obtained his contact information. I then connected with the CMS office and, with the further assistance of Barbara Tomar in our D.C. office, had a follow-up call with the CMS project team. I and a number of knowledgeable ACEP members and staff are now working to make more concrete suggestions to the CMS project team so that the survey will more accurately serve its purpose, which should be to improve patient care and clinical outcomes for patients. We are attempting to 1) decrease the number of questions on the survey so that a higher percentage of patients will complete it; and 2) modify the questions so that they are applicable to the ED rather than to the inpatient setting, e.g. the question “How often did the doctors and nurses do everything they could to help you with your pain?” is inappropriate in the setting of the opioid epidemic we are experiencing. I am hopeful we can revise the final accepted survey.
There are a number of other issues with regard to creating financial incentives using ED PECS. The first is the survey itself. The second major area of concern is the methodology by which it will be implemented. While many emergency physicians rail against Press Ganey & Associates because they are the largest and best known patient satisfaction survey company, they at least typically survey several hundred patients per month. In contrast, many of the other companies (including the company currently used at my hospital) usually survey as little as 100 patients a quarter. If ED patient satisfaction is to be used as any sort of incentive, a statistically valid sample size must be obtained for each physician. We as physicians are data driven, and give us metrics which we can believe and trust and we will change and get better. Without data it becomes smoke and mirrors. The minimum number of returned surveys needed is recognized to be no less than 30 surveys, and ideally 50. This number should be captured within a short enough time so that physicians who want to enhance their scores can see that their specific actions are improving the patients’ perceptions; ideally this should be 50 surveys per quarter. With the current practice, it would take two years in most ED’s to get an adequate sample size for each individual provider, and that is absurd. The methodology at present is terribly flawed.
The third problem area is the potential for misuse of the patient experience scores. Some administrators have used this metric to credential emergency physicians and to designate them with regard to quality. While the patient experience is one of the dimensions of quality, it is only one of the six designated by the federal government; others include clinical effectiveness, patient safety, care coordination, and efficiency. Guidelines need to be developed so that any ED PECS scores which are tied to individual physicians may be interpreted by medical group and hospital leaders in an appropriate manner.
Robert E. O’Connor, MD, MPH, FACEP
Professor, Chair, Physician-in-Chief, Department of Emergency Medicine, University of Virginia Health System, Charlottesville, Virginia; Emergency Physician, Culpeper Regional Hospital, Culpeper, Virginia
The challenge that arises when discussing “financial incentives” for patient “satisfaction scores” is that most emergency physicians view these programs with caution and skepticism. Everyone has heard about colleagues who have been financially penalized or have even lost their contracts based on “poor” survey results. Most emergency physicians question the validity of any survey that has so much importance attached to it, yet evaluates only 10 percent of discharged patients (admissions are excluded), with a 10 percent response rate, representing 1 percent of patients seen. Within this context, CMS is piloting the ED-CAHPS survey, which has drawn a lot of attention from the emergency medicine community.
In an effort to measure and promote care that is patient-centered, CMS has been required by the Patient Protection and Affordable Care Act of 2010 to implement payment and public reporting programs using data collected from CAHPS. Three such programs that are fairly well developed are the Hospital Value-Based Purchasing and Hospital Compare Programs that have been developed using data from HCAHPS, and the Physician Compare program, which uses data collected from the CAHPS Physician Group Survey. Efforts to use CAHPS surveys to assess a wide array of health care entities are currently underway and includes nursing homes, Health Insurance Exchanges, behavioral health, Accountable Care Organizations, and dialysis centers, to name a few.
The CAHPS surveys are designed to focus on the patient care experience while deemphasizing patient satisfaction, which is a subtle, yet crucial, distinction. Two examples, taken from the ED-CAHPS pilot, illustrate this. Instead of asking how satisfied the patient was with the time it took to be seen, the survey asks “When you first arrived at the emergency room, how long was it before someone talked to you about the reason why you were there (Less than 5 minutes – 5 to 15 minutes – More than 15 minutes)? The survey also measures global ratings such as “Using any number from 0 to 10, where 0 is the worst care possible and 10 is the best care possible, what number would you use to rate your care during this emergency room visit?” The ED-CAHPS survey is intended to allow for comparisons across a wide variety of hospitals, locations, medical conditions, and insurance types.
Three versions of the survey have been field tested, one for patients discharged to the community, one stand-alone version for patients admitted to the hospital, and a version for patients admitted to the hospital that will be administered as a supplement to the existing HCAHPS survey.
But does the patient experience correlate with quality? Results have been mixed. Patients who report a better experience tend to understand and comply with treatment regimens. Effective communication and trust in the physician results in a better patient experience and should be reflected in better survey scores. Feedback to providers is crucial. In one example, physicians who were initially deemed to be poor communicators with poor patient compliance could achieve improvements in both areas through communication skills training. In recognition of its importance, the American Board of Emergency Medicine has added patient feedback as a required component of the Assessment of Practice Performance component of its Maintenance of Certification.
Higher HCAHPS Scores have also been associated with better CMS clinical process of care measures, improved patient safety (fewer infections, fewer decubitus ulcers), and possibly better efficiency. Hospitals with lower HCAHPS scores were able to improve their scores by implementing programs that focused on the patient experience.
For ED-HCAHPS to be truly effective, the information that is gathered should give emergency medicine the opportunity to improve the resources that we oftentimes lack in the form of facilities, the admission process, staffing, and equipment. With the right questions, we will be able to gain a better understanding of how admission delays, cleanliness, and interpersonal interactions impact the patient experience. We should welcome our patient’s perspectives on hallways, crowding, and boarding and use the results to address all three as institutional problems.
This leads to my conclusions. The only financial incentives that I favor are ones that require that hospitals broadly administer the survey and report their results through the ED-HCAPS program. This will ensure that data elements are widely collected, and that the results are robust and comprehensive. I do not favor incentives based on score comparisons, as many factors contributing to these scores are beyond physician control. Instead of being a performance end point for the individual emergency physician, these scores should provide health care entities and physicians with the information we can collaboratively use to provide a better patient experience.
Rebecca Parker, MD, FACEP
Attending emergency physician, Centegra Health System, McHenry and Woodstock, Illinois and Presence Covenant Medical Center, Urbana, Illinois. Vice President, EmCare North Division. President, Team Parker LLC, Consulting Group Coding, Billing, and Compliance, Clinical Assistant Professor, Texas Tech El Paso Department of Emergency Medicine
Recently, Dr. Kevin Pho published a thought provoking opinion piece in USA Today about physician ratings on social media sites. Dr. Pho notes that the “Best physicians aren’t always the ones who have high satisfaction rates among patients.” Practicing emergency physicians feel the pressure of trying to meet patient expectations, while providing the correct diagnosis and treatment. Subjective survey questions focusing on throughput times and physician interpersonal skills run contrary to higher satisfaction scores when we have to discuss the death of a loved one or explain that the antibiotics or CT that the patient wants so badly is unnecessary. Regardless, hospital pay and our salaries are tied to these survey results.
There are concerns that the surveys influence physician behavior negatively. In theory, improving communication with the patient should improve quality of care. Studies show that improved communication improves patient adherence to the treatment plans, their understanding of their disease, and increases patient safety. Positive rapport and communication with the patient decreases the physician’s risk of liability; however, fear of a negative survey seems to influence the physician in the opposite way that we want. In a 2012 JAMA Internal Medicine review of more than 50,000 HCAHPS surveys, there was a disturbing correlation between higher patient satisfaction and higher health care costs, higher hospitalization rates, and higher death rates. In my opinion, the HCAHPS survey is not improving outcomes.
That said, the Patient Experience surveys are here to stay. And we all agree that improving the patient experience it is important. Hospitals and our in-patient physician colleagues have been submitting HCAHPS scores to Medicare since 2007, and we’ve learned from their experiences. And now, Medicare’s Value Based Purchasing program ties a portion of our hospitals’ Medicare reimbursement to HCAHPS scores, with physician Medicare PQRS payments soon to follow. Medicare views the CAHPS program as core to transitioning provider payment from quantity to quality: “the indispensible outcome.”
For years now, emergency physicians have dealt with patient satisfaction scores from private vendors. We analyzed the non-standardized survey questions and made the best of low response rates coupled with skewed percentile ranking systems. Emergency physicians used these surveys to accomplish their mission of improving care and patient outcomes by efforts such as demanding resources for throughput initiatives and improving both interdepartmental and individual physician communication skills. We listen better, keep the patient informed, and we mindfully explain our diagnosis and treatment plans to the patients and families. We also learned rounding techniques and follow up strategies to ensure that the patient gets the care they need or help if they get sicker. All these efforts result in better departments and better care for patients.
We need to take the same approach as we move toward ED-CAHPS implementation next year. The good news is that the new ED-CAHPS survey has improved reliability and a more reasonable scoring curve than the current ED survey instruments. Let’s take this opportunity to show Medicare the best way to measure the patient experience and to motivate emergency medicine systems properly. Right now, ACEP should share member observations and experiences with Medicare and work to mold the ED-CAHPS tool into an instrument that improves outcomes and access to care. Our opportunity is collaboration with Medicare by shaping these surveys to improve our practice, patient care, and resources.
Reimbursement is now based on the Patient Experience, and we’ve already learned hard lessons along the way. As we look to the future, ACEP should seize the opportunity to advocate for the patients, physicians, and hospitals through ED-CAHPS advocacy with Medicare. We need a tool that will help our patients get better faster, gives us communication feedback, and helps us find and fix the gaps in our health care system. Together we can help the patients, help the hospitals, and help ourselves.
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