Sauntering down Main Street in Palm Springs, with my friend Maureen, an Executive Director at Kaiser Permanente, our conversation turns to her work. She tells me that patients are an integral part of the Kaiser process and doctors are evaluated regularly by their peers and patients. She explains that performance has to do with the quality of care, not the quantities of tests.
The idea that our experience could impact the doctors’ rating and ultimately his/her wages may empower and create more of a teamwork atmosphere deserves attention. But the system for most of us, patients and doctors, is set up with the physician as all knowing and patients as Lilliputians, insecure, often frightened, and far too often reluctant to ask questions.
Winds are shifting. Before the Affordable Care Act was the law of the land, other insurers, like Kaiser, started reimbursing physicians based on health outcomes rather than services and tests. This in addition to online feedback forums, such as healthgrades.com and webmd.com.
“We are going to be responsible for outcome measures that we have no control over, such as whether patients follow our instructions or take their medication.” says pediatrician Jesse Hackell. Parents who refuse to have their children vaccinated or who frequently opt to take their children to emergency rooms or urgent care get a letter from Dr. Hackell. “[We] can’t be responsible for the child’s overall health it they continue to use these services.”
This trend to shift payment from volume to value inspired a study to see how it was affecting patients. Are physicians limiting the patients they see to those whom they can demonstrate value to improve revenue? The study concluded that those who responded were dismissing patients not for fear of poor evaluation, but because of their disruptive behavior (repeatedly missing appointments), and patients taking opioids (violating a pain management contract). The American Medical Association provides guidelines for when a doctor may refuse to see a patient.
Department of Family Medicine and School of Medicine and Public Health in Madison, Wisconsin conducted a study to evaluate “the clinician-perceived effects of patient satisfaction ratings on job satisfaction and clinical care.” The outcome suggests that using “patient satisfaction surveys” led to physicians’ job dissatisfaction and medically inappropriate care. They found the result intriguing and called for more studies to examine the link between the patient’s experience of care evaluation and physician practice satisfaction.
Most of us don’t look forward to a performance review. Even when we believe we’ve done a bang-up job, a residue of worry remains. Bosses worry that even the mildest criticism will be met with stonewalling or anger. So, patients say as little as possible. What can I say? Perhaps they’re right. They’re the doctors, after all. Clinicians don’t ask for feedback. Did I answer all your questions? What concerns you most about what I have shared?
Purchasing headphones on Amazon I expect an email asking me to rate their product online. There is an inherent risk that a customer may unfairly rate the product and cost the business sales. In today’s environment, online evaluations are the cost of doing business. It’s reasonable to think that an occasional low rating won’t greatly impact the truer outcome. Understandably, businesses have mixed opinions. But the doctor community has opposed consumer review of their services to unusual degree. Why?
Eric Goldman, Santa Clara University School of Law (2013), attempts to answer this question. Patients lack the medical knowledgable to evaluate the medical advice. Unlike businesses, confidentiality restricts doctors’ ability to respond. Doctors are sensitive about their reputation.
On the other hand, Eric continues, “Patient reviews matter. Historically, patient opinions about the quality of their healthcare didn’t matter too much. Many doctors got patients through hospital/insurance affiliations and referrals from other doctors. Patient word-of-mouth also played a role, but doctors who failed to keep patients happy didn’t always suffer the professional consequences. Now, because patients can speak publicly about their experiences and influence other prospective patients, they have new-found leverage over doctors.”
What most of us want in a doctor is that s/he understands that the conversation we have with them is as important to us as any prescriptions, tests, scans, or surgery. Perhaps more.