Who Crowned the Patient King?

I suspect that physicians and other health-care providers who have dedicated their lives to health care find the whole patient-centered movement inherently irksome. Let’s face it: The movement implies that patients previously were not central enough to the work of caregivers. In fact, a case could be made that the exact opposite is true. Today, caregivers not only have to give the care that they gave in the past, but also must document it, footnote it, and serve it up on a silver platter, leaving less time for care delivery. Is this hyperbole? A few weeks after new payment rates based on the 27-question Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey went into effect, an article¹ in the Wall Street Journal documented what the movement has meant to Grady Memorial Hospital (Atlanta, Georgia), a level I trauma center: wild-caught salmon on the menu and ESPN in the rooms. The facility had turned a $55 million deficit in 2007 into an anticipated $1 million surplus this year—only to be dinged for lower-than-average HCAHPS scores. When did patients become king? That role previously was reserved for the physician, but now Grady Memorial Hospital is counseling physicians not to interrupt patients and to get down to eye level when communicating with them. With nearly $1 billion in payments based on the HCAHPS survey at risk this year, hospital administrators are not thinking about evidence-based medicine, upgrading old technology, or other clinical matters. They are focused on how to get their patient-satisfaction scores high enough to prevent revenue losses: Grady Memorial Hospital’s CEO expects it to lose $230,000 in federal payments this year due to its lower-than-average patient-satisfaction scores. This is pay for performance, but the performance is more show business than health care. Patient Experience and Pay Patient experience is one of four types of pay-for-performance measures identified in a new policy brief² from Health Affairs and the Robert Wood Johnson Foundation. The three other measures are process (for example, in radiology, steps taken to prevent nephrogenic systemic fibrosis when imaging calls for the use of contrast media); outcomes (such as recall rates for screening mammography or complications following interventional-radiology procedures); and structure (such as the facilities, personnel, or technology used). The brief states that despite mixed results for pay for performance through the past decade, we are likely to see even more of this approach, in the near future, because health policy experts look on it fondly—and the Patient Protection and Affordable Care Act expands the use of these techniques. Another factor in play might be even more powerful than policy-driven pay for performance: Patients are playing an increasing role in the financing of health care. The patient became king when the patient became a customer. This is something that outpatient radiology has understood for some time— and that hospitals are now discovering, through the HCAHPS experience. This issue’s cover story (page 18) dips into the subject of what patients are seeking from a radiology provider, which is currently rather basic: convenience. Another feature in this issue tells the fairy-tale story of how one hospital transformed bottom-quartile scores (from Press Ganey) for customer satisfaction with outpatient imaging into scores that place it in the top 10% of all hospitals. It will resonate with great leaders everywhere because it is about the power of team dynamics and a triumph of cultural change. Something to It The patient-centricity movement is rooted in some well-documented shortcomings of our health-care system. Over the past 15 years, evidence has mounted to indicate that in the United States, our past approach to health care is riddled with error, is uncoordinated, and (in comparison with the systems of other nations) is less effective and more expensive. Looping patients into the process not only is a good idea, but is impossible to avoid, now that patients are footing more of the bill. Besides that, when you think about what a meal costs in a hospital, the food really should taste like food—and as Rhonda Scott, PhD, chief nursing officer at Grady Memorial Hospital, told the Wall Street Journal, “requests for pain medications go down during the afternoon football games.”¹ Nonetheless, I think we need to ensure that patient-centered radiology doesn’t tilt too far in the direction of pampering the patient. Patient-centered care is not enough. In the rush to give patients their due, government and health-policy experts have glossed over one important element: patient responsibility. In order to get closer to the goal, we need to move the goalposts and transition to a more positive approach to consumerism in health care: patient engagement.