The idea that patient experience might be weighted by a regional "grumpiness factor" reminds me of the comical Mrs. Hufnagel, the obnoxious patient in the 1980s TV hospital drama, St. Elsewhere.
No matter how hard hospital teams tried to please her, she always complained, in her grating, gravelly voice. For those who didn't watch the show, Wikipedia provides this appropriate description: "She insulted nearly everyone who tried to help her and was disliked by nearly the entire St. Eligius (Hospital) staff."
Now, as it turns out, hospitals in certain regions of the country are suggesting, in effect, that a disproportionate number of Mrs. Hufnagels seek hospital care in certain parts of the country, specifically New York, New Jersey, and Pennsylvania.
That's the one region, out of nine in the U.S., where a Press Ganey survey last year shows hospital patients are least likely to recommend that facility to friends and family.
Is the care provided in those hospitals really worse? Or is it possible that – generally speaking of course – the culture in those states favors the curmudgeon? They've got an attitude, and even if providers' give perfect care, all you get is a grumble? Maybe grumpiness is, to a greater degree, expected?
On the other end of the response spectrum, more easily pleased and willing to recommend their hospitals are those patients in New England states and those in the Great Plains: Iowa, Kansas, Minnesota, Montana, Nebraska, and North and South Dakota.
As Blair Childs of Premier Health Alliance suggested in my interview with him last week, "It might be less a function of what the hospital does than the attitude of the population. For example, In New York City, they are grumpier than they are in Minneapolis."
According to the proposed value-based purchasing algorithm, released by the Centers for Medicare and Medicaid Services earlier this month, if there is indeed a grumpiness differential that goes uncorrected, it's going to unfairly cost hospitals money. If the 126-page proposed regulations are approved, the nine-month scoring period will begin July 1. And now, more than before, hospitals are starting to take these survey questions more seriously.
Under the proposed regulations, 30% of a hospital's value based purchasing score will be weighted on patient experience based on the answers they give to eight survey questions.
Not only is 30% too high, but even 20% is unfair, says Vincent Fitts, associate vice president of informatics for the Greater New York Hospital Association.
"Wholly separate from the apparent regional bias in HCAHPS results and the fact that large urban hospitals generally fare worse, the current formula penalizes hospitals that treat a higher-than-average percentage of patients for whom English is a secondary language – even though they tend to express satisfaction with their care," Fitts says.
"We simply don’t think HCAHPS scores accurately reflect patient experience in the New York metropolitan area.”
The questions cover communication with doctors and nurses, responsiveness of hospital staff, pain management, communication about medicines, cleanliness and quietness of hospital environment, discharge information and overall rating of hospital.
I asked Nate Kaufman, a hospital analyst who flies around the country consulting with healthcare systems and physicians about the Affordable Care Act, what he thought about a "grumpiness differential."
He has a much different perspective. In his view, those hospital groups that are complaining doth protest way too much.
"It's a ridiculous argument," he says. "When Toyota is giving out customer satisfaction bonuses to auto dealerships around the country, do you think they give a better break to the guys in Kansas? No.
"Maybe the folks in New Jersey, New York and Pennsylvania just need to work harder," he says. "It's about time that if people in hospitals don't satisfy patients, and don't provide the best science in medicine to those patients, they should have some sort of consequence."
Jason Rau, president of NRC Picker in Lincoln, NE, another healthcare survey company similar to Press Ganey with about 700 hospitals, says he can't comment on whether a 30% weight is fair across the country, but he acknowledges that there are regional differences in the way patients answer questions. But whether it makes that much of a difference is unclear.
Besides, he says, CMS is already making some demographic and patient mix adjustments in how value based purchasing scores are weighted. It bears some looking into, he says. But "in the end, maybe services provided really are different."
Jessica Kennedy, also of NRC Picker, posted this comment to our Monday story about the hospitals' concern.
"This article may be asking the wrong question," Kennedy wrote.
"Maybe the experience of care patients have is different depending on what institution they're in or where they live. So perhaps this is not a question of patients being grumpy... Perhaps it is a question that we in healthcare are not equally committed or able to provide patient experiences that meet the expectations of our patients and their families."
As Premier's Blair Childs suggests, this is bound to be a hot topic of debate. "This is a concern and we have to look carefully from the vantage point of the data, to see how fair this is, and to ask what is fair," he says.
By the way, Mrs. Hufnagel was not a patient in New York Hospital. The TV series' imaginary hospital was located in South Boston, in a region with the highest patient satisfaction responses, according to the Press Ganey survey.
And maybe she had a right to be unhappy. After all, in that show, she died in St. Elegius when the folding bed she was lying in collapsed in a V and suffocated her.
It's going to be an interesting exercise to see if there is a grumpiness culture that pervades these three Northeastern states, and to a lesser degree others along the eastern and western seaboards more than the rest of the nation. But absent any definitive findings, I'm with Kaufman.
Maybe these lower-scoring hospitals should just try harder.