If you hired a lawyer who the world’s nicest office and excellent coffee in the lobby, but who lost the case for you every time, what would you think of that lawyer? How about if you hired a hairdresser who was always on time and had some great gossip for you when you sat in their chair, but who made you look like a refugee from Flock of Seagulls every time you left the salon? I am guessing that your general view on these people would be negative, despite their incidental charms.
However, when people are asked to rate their doctors, it is precisely the incidental charms that count the most. The primary correlates to doctors receiving high patient satisfactions scores are: 1) whether they were made to wait for an excessive period of time in the waiting room; and 2) whether the doctor spent a long period of time with them in the exam room. In other words, patients value comfort and attention and that, in their minds, tends to equate to high quality care. Buyer beware.
In mid-December 2011, a research team from the University of Michigan School of Public Health analyzed data from around 15,000 patients who used a patient satisfaction survey tool called DrScore.com. What they found is that, on average, patient satisfaction with their own physician ranks in the 90th percentile. The categories most highly correlated with satisfaction were, as previously noted, waiting time and amount of time spent with the patient. I don’t know about you, but if I’m ranking my doctor, I’d be thinking about outcome and invasiveness of treatment as a big part of how I feel about them. And yet, the question of whether their illness was effectively cured or whether they suffered unanticipated side effects is not nearly as big a factor in patient satisfaction as is the courtesy of the office staff and the timeliness of appointments and follow-up.
If you look at the questions asked in the DrScore survey, which you can find HERE, you see that only 2 of the 20 non-demographic questions in the survey get directly at clinical outcome. The first is: On a scale of 1-10, how do you rank your treatment success? This question is actually number 11 of the survey of 20 questions. The second question is more indirect, asking “on a scale of 1-10, where 0 is the worst possible care and 10 is the best possible care, where do you rate your doctor?
So what? You might ask. Patient satisfaction has been measured this way forever. If people are happy with their doctors, then good for them.
True, but here’s the rub. If you ask people if they are satisfied with the healthcare system and whether they think they get good value for dollars spent, they say “no.” As many as 80% of Americans say they are dissatisfied with the U.S. healthcare system in typical surveys. If you ask people if they think money is wasted in excessive treatment they say “yes.” If you ask 100 people if they have a friend or family member who got bad treatment and/or harmed by the medical care they received, you will get 100 yesses. And yet those same people who hate the medical system love their doctors. It’s similar to how people separate their feelings about “Congress” from their feelings about their own Congressional representatives. When you poll voters, they tend report 70%-80% dissatisfaction with how Congress is doing its job and 60-70% average satisfaction with the efforts of their own congressional representative. No wonder you can never get rid of any of these people.
I have to believe this consumer schizophrenia is one of the reasons it is so hard to change the healthcare system for the better. Payers have tried for years to effectively reduce the size of their provider networks to reward physicians who demonstrate better outcomes and to exclude those of less clear quality (the basic idea around pay-for-performance). Yes, no doubt these things are hard to measure in the aggregate; everyone wants to bring in risk-adjustment and all that other stuff. But for one individual patient, it is pretty easy to measure these things. I go to my doctor; he/she makes me feel better or not. I feel more in control of my health or not. Etc. Yet whenever a payer tries to cut any provider out of its network, bedlam ensues as consumers fight the perceived reduction in choice. And this is because every provider has his/her fans, not because every provider is effective. I used to work for a doctor that used to always tell me, “by definition, 50% of doctors are worse than average.” Hard to argue with that logic.
As health reform rolls along–and it will roll along in some form or another because the economic imperative is there regardless of the form the final law takes–it will become necessary to force more accountability into the system. A big part of that accountability will and should fall in the lap of consumers, who are, in the end, responsible for what happens to them and how their own money is spent. It will be interesting to see whether consumers will be willing to trade the provider of their choice (he has such great lollipops!) for the provider that costs less or delivers faster or better results when push comes to shove and their own cold hard cash is at stake. Certainly those would be the primary determinants in any other significant consumer purchase. No one buys a car because the dealer is highly attentive and has fresh minty breath or a piece of real estate because the realtor has such a nice car and is a good listener. People are able to rapidly overlook these things if they think they are not getting a good value.
Over the last several years many new businesses have formed that are focused entirely on delivering quality and cost results to consumers so they can make better provider choices. Virtually all of these are still pretty small enterprises with fairly light levels of consumer adoption. Yet as consumers are put in the driver’s seat for the purchase of health insurance plans, as they will be through the health insurance exchanges that will likely soon be pervasive, will these businesses become as popular as Consumer Reports is for cars and appliances? Today the average person spends far more time interviewing contractors and financial advisors than they do physicians; will this change when consumers have a greater sense that it is their own money being used to pay physicians? Taken to its logical extreme, maybe the next big reality show will be the one where physicians compete for consumers’ affections and get voted off the island by Paula Abdul when they fail to deliver in the charm department.
One of the questions on the DrScore.com is “to what extent does your doctor include you in decisions about your care and treatment?” This reminded me of that Seinfeld episode where Elaine’s doctor decides she is “difficult” and writes secret notes in her file before blowing her off with a cursory treatment plan. When she goes to the next doctor, he has already received her records (what are the odds of that happening in real life?) and treats her with the same disdain, driving she and Kramer (posing as Dr. Van Nostrum) to try to steal her medical records. Thought I’d include the video clip of that scene, as it always cracks me up. I’m guessing these guys wouldn’t have fared so well in the DrScore.com study.
Eric Page says
To me, your main message indicates the fallacy of the consumer driven healthcare models you discuss towards the end (my answer to your question is No, at least not on their own). Our health is different from anything else we purchase. Health is a necessity, everything else a relative luxury. We would opt for the expensive car repair far more often if we only had one car for the rest of our lives.
Until patients and their primary care physicians are aligned towards better health outcomes, I’m not convinced that consumer driven health businesses will have a major impact. It’s a tall order to get consumers to trust a piece of technology more than a physician who looks them in the eye, touches them, and tells them that the expensive treatment is the right one.
btw, I think you underestimate the value of fresh minty breath and being a good listener. At my last business (sleep medicine), our fresh breathed RTs delivered a 20% higher adherence rate to CPAP machines by simply shaking hands with a patient before their sleep study vs. after.
Lisa Suennen says
Eric, I wonder if the co-incidence of freshly breathed/hand-shaking RTs and compliance is causality or correlation. Hard to parse all the variables. But no doubt patients and all people are more conducive to listening when treated with respect. Lisa
Lisa, very good observation and great post as usually. I think, a possible explanation as to why patients tend to care about time spent with patient in the office or “holding hand” pattern is b/c most of them come to see doctor for minor problems like cold, back pain etc. (and the poll was conducted with primary care doctors if I am not mistaken). However, when it comes to a specific condition (angioplasty, delivering a baby, ortho surgery) skill set and professional track record will dominate the choice (or may be I am naive). In other words, I don’t care if my doctor is a jerk if he is a top cardiologist and knows what to do.
Lisa Suennen says
Milena, could not agree more!Lisa
Dan Munro says
Valid points all – but as your post (and Seinfeld skit) highlights – informed consumers (patients) are the last consideration. Lot’s of industry buzz around “patient-centricity,” but an awful lot of it is lipstick on the pig. “Mint for healthcare” is an interesting concept – but it’s not deliverable without full pricing transparency – PRE-event. Post treatment information/analysis is interesting – but doesn’t exactly give me control over pre-treatment options. Keas found this out – others will too.
Case in point. Any given hospital is likely to perform hundreds of hip and knee replacements every year – but here’s a challenge. Walk into any one of them and ask how much either a knee or hip replacement costs? If you do get a reply (vs a blank stare) it will look very much (from a consumer perspective) like “… uh … I don’t know … how much you got?”
Innovation and Legislation needs to re-align that – and it’s a monstrous effort/undertaking. To your exact point – that will take years and many swings of the legislative bat to get to value alignment over volume alignment.
Pricing transparency aside – we’re already seeing a provider backlash to more engaged consumers. Post pending on exactly that shortly – which I find really troubling – especially at these earliest of stages.
Lisa Suennen says
Hi Dan, yes, all valid points. No one likes it when their revenue is at risk. Lisa
Eric page says
Lisa, agreed that it’s hard to parse the variables but the evidence points strongly towards causation. For brevity, I simplified what was different but it was the same patient process flow with the exception of when the patient met the RT. of course, other variables had an effect such as referring provider and the patient’s insurance. we also had concrete measurements for certain insurance plans and relied on patient feedback for others.
Overall, the trends were clear and in favor of causation. My new company is taking our lessons learned in sleep to the broader healthcare industry so I’m putting more effort into truly dissecting why/what is causal. If I learn something new, I’ll let you know.
Dion Madsen says
Except in Lake Wobegon where all the doctors are above average. Great post Lisa and thank you for pulling one of my favorite Seinfeld episodes.
Laurie Orlov says
This misses the point — most people have no idea in advance if the treatment they are about to get will be harmful or helpful. Example: 25% of patient hospitalizations result in infection (even in so-called ‘good’ hospitals.) Hard to know if you’re in that population before you get there. The impact of prescribed medications is equally murky. Further, for the most part, ‘your’ doctor is simply a traffic cop, referring you here, there and everywhere.
Your doctor is all you have as a contact point when things head downhill — and is the primary person to thank even when you survive and get home safely. Is it a surprise that patients value the friendliness and allocated time spent by this single person who, unless you can prove outright negligence, is all you have?
Satisfaction is an odd measure for evaluating a service over which you have virtually no control.
Lisa Suennen says
Laurie, thanks for the note but I respectfully disagree. Not suggesting people should know in advance if their doctor helped them, but rather be able to evaluate satisfaction with their care providers by how they fared afterwards; we rate many services based on which we have no control: restaurants, airlines, physicians…. Lisa