Opinion: Emergency Physicians Should Take Cautious Approach to Incentives that Boost Patient Satisfaction

Jay Kaplan MD, FACEP, recently argued in ACEP Now (April 2014) that emergency physicians should embrace patient experience metrics because patient satisfaction has been linked to patient adherence to evidence-based recommendations and improved clinical outcomes. However, Dr. Kaplan was selective in his review of the literature and, at times, erroneous. We believe that emergency physicians have legitimate concerns about the potential misuse of patient experience metrics and that Dr. Kaplan’s enthusiasm is unjustified.

Dr. Kaplan concluded that the literature overwhelmingly supports a causal connection between patient satisfaction and clinical care quality, citing a 2013 BMJ Open review.¹ However, this review included studies utilizing sophisticated patient communication measures bearing little resemblance to widely used patient experience metrics. Key negative studies were excluded from the review, including a Dartmouth Atlas analysis that found no consistent relationship between satisfaction and clinical care quality.²

Indeed, the Dartmouth Atlas study is consistent with other studies of the relationship between patient satisfaction and technical health care quality.³ While some literature supports an association between patient satisfaction and adherence, patient satisfaction is affected by factors frequently unmeasured in satisfaction studies. In a nationally representative sample, unadjusted positive associations between patient satisfaction and preventive care adherence were eliminated, or even reversed, with sequential adjustment for patient sociodemographics, physical and mental health status, and attitudes toward health care.⁴

Meanwhile, Dr. Kaplan criticized a study one of us published.⁵ Within a nationally representative sample, the study found that patients in the highest patient satisfaction quartile (versus the lowest) had 8.8 percent greater total health expenditures, 9.1 percent greater prescription drug expenditures, and significantly higher mortality over a mean follow-up of 3.9 years. The study adjusted for patient-level covariates often not included in prior investigations, including physical and mental health status, chronic illness, and prior health care utilization. The results highlighted the need to better understand the potential link between patient satisfaction and health care utilization, including the use of health care that may, on balance, be harmful.

Dr. Kaplan stated that the study “has no legitimacy” due to three “serious methodological flaws”: 1) that satisfaction was only measured in 2000 and not in later years, 2) that drug and total expenditures were only measured in 2001, and 3) that mortality was assessed in 2001–2006 and never in years when satisfaction or cost were measured. Each statement is false. Regarding the first two, relationships between patient satisfaction and utilization were studied all years from 2000 to 2008. Regarding the third, satisfaction in 2000–2005 and mortality outcomes through 2006 were assessed for the subsample initially enrolled in 2000–2005.

In our view, the evidence supports a conceptualization of satisfaction as a quality metric unrelated to technical health care quality. Technical care quality is often invisible to patients. Consider the delivery of antibiotics within six hours in patients diagnosed with pneumonia in the emergency department. Patients will likely be oblivious to this care process but will be sensitive to wait times or any noise or odors near them. They will also care about how their physicians communicate with them, and for this reason, physicians shouldn’t be nihilistic about patient experience metrics.

Physicians have a responsibility to understand and address patient expectations during medical encounters, and unmet expectations are a key driver of patient satisfaction. Emergency physicians should strive to identify what patients want from their encounter and to address those expectations with empathy, tact, and respect—but there are crucial caveats. Physicians are obligated to steer patients away from tests or treatments that are either low-value or inappropriate, even if patients request them. Physicians are also obligated to deliver unwelcome news and to counsel patients about risky or self-destructive behaviors. We believe all physician duties can be carried out in a humanistic, patient-centered manner, but the primary goal of many emergency encounters is more nuanced than achieving an “excellent” patient satisfaction rating.

With the impending launch of the emergency department version of the Centers for Medicare & Medicaid Services’ Consumer Assessment of Healthcare Providers and Systems survey (ED-CAHPS), we argue for a cautious approach to incentives to boost satisfaction. These metrics may be helpful in identifying physicians with communication problems. However, incentives should not dissuade physicians from professional obligations to steward resources wisely and to engage in conversations that may challenge patients at the risk of making some dissatisfied.

Incentives also should not discourage physicians from caring for subgroups that may be more difficult to satisfy (eg, Medicaid patients, patients with mental illness or chronic pain). Lack of health care access may lead to fragmented care for these subgroups and an increased reliance on emergency departments. Questions remain regarding what drives these metrics and how they relate to personal and population health, calling for a measured approach to interpreting and rewarding patient satisfaction.