Blog | Thursday, April 26, 2012

Don't confuse a happy patient with a well one

Patient satisfaction is all the rage. Medicare is beginning to tie patient satisfaction scores with hospital reimbursement, and doctors across the country are under pressure from administrative executives to raise patient satisfaction scores. High scores are even used by hospitals as a powerful marketing tool.

But, in the end, are patient satisfaction scores hurting patients?

I wrote about the issue previously, saying that patient satisfaction scores reward rich hospitals, as well as a previous USA Today op-ed, warning that catering to patient demands may not be in their best interest: "Quality health care sometimes means saying 'no' to patients, denying them habit-forming pain medications that can feed an underlying, destructive drug addiction, or refusing to order unneeded CT scans that can facilitate harmful radiation exposure.

But Edwin Leap, a nationally recognized physician columnist at Emergency Medicine News, notes that doctors 'are constantly under the microscope to give patients what they want, since 'giving people what they want,' has been tragically, and falsely, equated with good medicine.'"

So it comes as no surprise that a recent study from the Archives of Internal Medicine has confirmed most physicians' fears.

According to the study, "compared to the least-satisfied patients, those who were most satisfied with their healthcare were on more prescription medications, made more doctor's office visits and were more likely to have had one or more hospital stays, despite the fact they were in better overall physical and mental health. Also, despite the greater attention and all those prescription drugs they got, the highly satisfied were more likely to die in the few years after taking the survey than were those who pronounced themselves least satisfied with their physicians' medical care."

As emergency physician WhiteCoat aptly puts it, "High satisfaction with a health care facility means that you're more likely to be admitted, you're more likely to pay more for your care, and you're more likely to be discharged in a body bag."

Not only are satisfied patients more likely to die, they cost more: "Overall, the most satisfied patients incurred 8.8% more healthcare expenditures than did the least satisfied and spent some 9.1% more on prescription drugs than did the least satisfied."

Our health system provides overwhelming incentives to "do more." The flawed fee-for-service payment system gives a financial carrot to order more tests. The emphasis on patient satisfaction pressures doctors to acquiesce to demands for medications. And finally, the malpractice system punishes doctors for not ordering, or not referring, enough, never for overuse of medical resources.

We need are more incentives to do less. Reward doctors for sticking to evidence-based clinical guidelines. Back them up for saying "no" to patients, at the risk of lower satisfaction scores. Educate the public that more tests can, in fact, be harmful.

And now, patients need to know that a hospital with a high patient satisfaction score isn't necessarily a good thing.

The Archives study shows that patient satisfaction raises health costs and kills patients. How much more data do we need before realizing that patient care and patient satisfaction cannot be mixed?

Kevin Pho, MD, ACP Member, is an internal medicine physician and on the Board of Contributors at USA Today. He is founder and editor of, also on Facebook, Twitter, Google+, and LinkedIn. This article was originally published on