The rise of consumerism and the arrival of quality surveys for physician practices means doctors will have to pay more attention to patient relationships. Providers can be choosy, but so can patients.
When I am sick, even if it is just a minor cold, I am cranky. My husband could regale you with tales of my despondency and general bad attitude when I do not feel 100%. I, too, have the dirt on him, on my son, and well, nearly everyone in my family. You likely know exactly what I am talking about.
So I empathize with physicians and nurses because they see us at our worst. Not only are we going to them for the magic pharmaceutical to knock out a nasty bug or manage a chronic condition, but we also go to them expecting some sign that they care about us. Hearing, "I hope you feel better," from not just the doctor, but also the nurse and receptionist, can go a long way in building loyalty to a particular practice.
Individualized attention may be an unrealistic patient expectation, especially with the limited amount of time doctors have with patients, but it's a reality. Add the additional wrinkle of social media, and one bad interaction could lead to a ding in a practice's reputation, its market share, and eventually, its revenue, via lost reimbursements.
Data collection for CG-CAHPS, the clinician and group practice version of HCAHPS, the quality survey that the Centers for Medicare & Medicaid Services uses to measure patient satisfaction, began this year for practices with 100+ eligible medical professionals who participate in the physician quality reporting system (PQRS).
Patient responses could begin impacting reimbursement in 2015. By 2016, it's expected that reporting on patient satisfaction at practices will be mandatory for groups with 25+ medical practitioners, and that up to 4% of reimbursement will be at risk. A final CMS rule on that is expected later this year.
Forward-thinking physician groups have already begun training everyone, from the front office receptionist to the lab tech, on communication techniques that contribute to a positive patient experience.
"There's an increased awareness of how things should go," says Laura Palmer, FACMPE, senior industry analyst for MGMA, an organization that represents 30,000 medical practice administrators and executives. "Patients have more invested because they're paying more of the bill."
Palmer says CG-CAHPS is not putting as much pressure on physicians as social media channels are, such as Facebook and Twitter or consumer rating and review sites such as Yelp, and Angie's List.
"Physicians are not automatically happy with being in that environment [social media]," she says. "We coach them and want them to respond to comments. We tell physicians, 'Any feedback you get is relevant and worth investigating.' "
Knowing that they will be graded on their customer service, some physician groups are also turning to third-party survey groups, such as Press Ganey, the South Bend, IN-based consulting group specializing in improving patient satisfaction.
Palmer says surveying patients is a common practice, but another challenge physician practices face now that they didn't previously, besides the ubiquitous and instant social media feedback, is that there are more patients.
"There are lots of challenging situations in offices," says Palmer. "We've got new people entering the healthcare system, and maybe their expectation of care is based on their ER visits, if that's the primary place the patients sought care before now."
Handling Complaints
An oft-quoted study from the mid-90s estimates that "difficult" patients make up 15–30% of a physician's panel in primary care. There are myriad characteristics that will push a patient into the "difficult" category, such as drug-seeking behavior, rude and/or harmful behavior, but what about the patient who is not easily satisfied? Or just a personality mismatch? Do you cut them loose?
Thomas H. Lee, MD, a practicing internist and cardiologist employed by Boston-based Brigham and Women's Physicians Organization, says it's a complicated question he's faced twice in his 35 years of practicing medicine.
"These are relationships that are analogous to marriage. You don't bring up divorce every time you have a disagreement," he says.
In both cases, Lee ended up keeping the patient, but each patient presented a different scenario. One patient made "insulting, sexist" remarks about a colleague of Lee's who happened to be Lee's wife. The patient apologized and both moved forward with a doctor-patient relationship.
The other patient represents a more complicated, but not uncommon scenario. This patient believed she was allergic to generic drugs (she was not), and refused to take medicine she was prescribed. Lee wrote about his experience for the Annals of Internal Medicine about 10 years ago as a way to explore the ethical dilemmas presented by difficult patients.
"I cracked and gave her the brand name drugs," says Lee. "Ultimately, I realized it was about me. Being a good doctor is not just checking off items on a checklist. It is being the kind of physician each individual is hoping for."
Lee is also chief medical officer at Press Ganey and works with physicians and healthcare executives to help them understand that the relationship with a patient is usually worth saving.
Cutting Patients Loose
Not all physicians are invested in keeping patients who may be considered difficult. But there various and differing state laws that regulate the practice of dismissing a patient.
The American Medical Association's guidance is to wait until a patient is stable, then notify the patient in writing with physician recommendations.
That did not happen with one patient in Tennessee, who told me that his physician's office dismissed him the same day he returned a survey from the practice. [Because I have not reached his physician to verify the claim, both names are being withheld.]
"I got an email survey and I gave the practice all positive marks except for my experience with the receptionist," he says. "I didn't say it was terrible, I just marked neutral. She was snippy, and talked to me in a hateful tone. I'm just left hanging."
This man says he's been seeing the same physician for more than 15 years, and his entire family uses him, or used him. This patient may be the one who was dismissed, but his family members are looking for other doctors, too.
"What's strange is the last time I was in his office… he made a point to say, 'You know, it's patients like you and your family that make me work harder.' This is why I'm totally shocked."
According to Lee, this type of dismissal is rare. And, he says, unfortunate.
"Physicians dropping patients because they haven't made the relationship work is not a good strategy," says Lee. "Speaking as a doctor, to actually cut your relationship with a patient and do it responsibly is a lot of work. It's a lot less work to take care of that relationship."
Lee also doesn't believe that physicians dismissing patients is on an upward trajectory. First, because doctors need market share, and second because leaving a patient "hanging" opens up the possibility of a malpractice suit (and a bad online review).
"These are relationships," says Lee. "Different people have different needs. It's the job of physicians to look across the table and see a human being."
With the rise of consumerism and the arrival of CG-CAHPS, physician practices will have to pay more attention to the emotional, empathetic aspect of patient care. Doctors can be choosy, but so can patients.
Jacqueline Fellows is a contributing writer at HealthLeaders Media.