"The current system of reporting patient satisfaction scores is much more difficult for large, urban hospitals than for small, rural hospitals," says one researcher, raising discussion about whether there should be additional adjustments by CMS.
Some predictors of patient satisfaction seem obvious, such as good communication between doctors and patients. But a study published in the Journal of Hospital Medicine shows that there are some less obvious predictors that put certain hospitals at a disadvantage for patient experience scoring and, ultimately, for reimbursement.
Researchers at Mount Sinai Health System in New York City found that bigger hospitals and hospitals where many patients don't speak English as a first language were predictors for poor Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, whereas white patients and ones with higher levels of education were predictors for good HCAHPS scores.
That means large, urban hospitals that serve some of the most vulnerable populations are at a disadvantage when it comes to the current scoring system.
"It's been a long-standing feeling of many people in large academic medical centers that the current system of reporting patient satisfaction scores is much more difficult for those types of hospitals than for small, rural hospitals," says the study's senior author, Randall Holcombe, MD, professor of medicine, hematology, and medical oncology at the Icahn School of Medicine at Mount Sinai, and chief medical officer for cancer for the Mount Sinai Health System. "We wanted to look at this and see if there were any factors that seem to predict patient satisfaction scores."
Randall Holcombe, MD
Initially, Holcombe says he and his co-authors hypothesized that patient satisfaction scores would track with population density, as previous research has suggested. Indeed, they found that "scores were definitely better in the less populous states," he says.
But was population the only predictor?
"We decided to dig deeper and look at lots of different parameters," he says.
The researchers analyzed HCAHPS survey data from 934,800 patient respondents who were seen at 3,907 hospitals across the country, representing more than 95% of the nation's hospitals.
The predictors they identified were so strong that you could actually predict what a hospital's patient satisfaction score would be before any patient even filled out a survey, Holcombe says. The lowest satisfaction scores were from population-dense regions of Washington, DC; New York State; California; Maryland; and New Jersey. The best scores were from Louisiana, South Dakota, Iowa, Maine, and Vermont.
"It provokes discussion about whether there should be some additional adjustments considered by [the Centers for Medicare & Medicaid Services]. They now tie reimbursement to these hospitals to these patient satisfaction rankings," he says. "It's very important that it's a level playing field."
He notes that CMS already adjusts for certain factors when determining scores, such as whether patients filled out the surveys by mail or electronically and the age of the respondents.
"Adjusting scores is not a novel concept. [But] there were still additional factors that they could consider adjusting for," he says. "I've not heard anything from CMS yet, but I'd be happy to talk with them about our findings."
That sentiment is echoed by Sandra Myerson, senior vice president and chief patient experience officer of the Mount Sinai Health System. She responded to questions via email:
"Specialty surgical hospitals that only provide specific, planned, and elective procedures to insured patients who are well enough to undergo surgery realize a significant advantage to medical centers that provide care to every patient regardless of their ability to pay for services or their health status upon unscheduled admission, yet CMS does not adjust for these differences," "It would be great to see additional studies that support these researchers' findings—perhaps then CMS will pay attention."
If CMS does get in touch, the study can also show how adjusting for those other potentially unfair factors does, in fact, level the playing field a bit more for certain hospitals that are disadvantaged by the current scoring. The researchers created a formula to adjust for the biases they discovered and applied it to all of the hospitals in New York State. It did, in fact, readjust the rankings slightly.
"Seven of the hospitals in the top 10 still were" there, Holcombe says. "It didn't really blow up the rankings, it just refined them a little bit."
Whatever the setting, Myerson says the keys to providing a great patient experience "include seamless care coordination, on-time care delivery, and effective, compassionate, and empathetic communication with patients and their family members by nurses and physicians."
"We don't want to imply that our formula is an excuse for bad patient experience," he says. In fact, it could serve as something of a wake-up call for large urban hospitals to pay more attention to these factors. Does your hospital have adequate signage and translation services for people for whom English is a second language, for instance? It's something that Mount Sinai is keeping in mind, too.
"We've discussed this, and these point to areas where we can focus our efforts," Holcombe says.
Alexandra Wilson Pecci is an editor for HealthLeaders.