Detecting defects in hospitals
BY SHANNON PETTYPIECE, and STEPHANIE ARMOUR, Bloomberg News
The chief executive officer of an HCA-owned hospital recently went undercover, wearing a two-day-old beard and a baseball cap to pose as a patient entering his hospital. His goal: to spot and fix service flaws.
The covert mission was part of a bid to win some of the almost $1 billion in government payments for hospitals with top-ranked service. Across the United States, the program is encouraging tidier rooms and quieter hallways at the more than 3,000 hospitals that participate in "patient experience" surveys.
As welcome as those improvements may be, numerous studies based on earlier attempts to tie bonuses to performance suggest such incentives may do little to improve care. Rewarding hospitals based on patient's experience could also have unforeseen repercussions, doctors and economists say. Such incentives, for example, may harm patients most in need of care by discouraging hospitals from treating the elderly and the mentally ill, they say. Hospitals also have concerns.
"Patients who are critically ill, they're less likely to rate hospitals as highly as those going home with a healthy newborn," Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, the industry's main lobby group, said in an interview.
The surveys are part of a broader shift by the federal government and private insurers to pay doctors and hospitals based on performance rather than numbers of tests and procedures. Under the plan, the federally funded Medicare program for the elderly is withholding 1 percent of payments, or an estimated $964 million in fiscal 2013, to hospitals. The U.S. will pool the money and mete it out to hospitals based on how they score on a number of benchmarks related to clinical care and patient surveys. The pool will increase to 2 percent of Medicare payments in 2017.
Thirty percent of the bonuses will be determined by the 32-question patient experience surveys and the remainder will be linked to how well they meet such clinical measures as pre-operative procedures. The surveys, which may be done by phone or mail, include questions about cleanliness of rooms, how quiet it was at night, if pain was well controlled and whether doctors and nurses communicated well.
"The patient experience surveys are directly measuring the patient experience with care, communication with nurses, did they understand their medications," Patrick Conway, chief medical officer for the Centers for Medicare & Medicaid Services, said in an interview. "Asking patients directly is the best way to measure care."
A study of Massachusetts doctors found that patients who had insurance plans that paid doctors a bonus for improving patient health saw the same gains as those whose insurer didn't offer any extra payments, according to the research published in Health Affairs in 2008. The payments ranged from $10,000 for a small practice to $2.7 million for one of the state's largest doctor's groups with most doctors getting less than $2,000 each.
In some cases, doctors may be finding ways to manipulate the system, especially those that link bonuses to patient care, said Steffie Woolhandler, a professor of public health at CUNY School of Public Health in New York who has researched the effects of incentives on health care. With blood pressure, doctors can take multiple measurements and record the lowest one or round down, she said.
"If you are paying people based on some sort of scoring system you encourage gaming of the system," Woolhandler said. "You get things like in Great Britain where on paper it looks like you are improving quality except when you go to measure blood pressure in the population there is no difference."
"We have to admit, we haven't really found the right measures," said Dan Ariely, a professor of behavioral economics at Duke University in Durham, N.C. "There is a question of whether the things we can measure and reward physicians for are exactly what we want."
At Beth Israel Deaconess Medical Center in Boston, where many students at Harvard Medical School are trained, Kenneth Sands, senior vice president of health care quality, said the pay-for-performance systems for measuring quality health care are flawed on how they measure quality of treatment and on patient satisfaction.
For example, hospitals can be penalized for having a patient get an infection even if the infection was contracted at another hospital.
Sands said hospitals can also manipulate the system because they are providing the data used to measure themselves. Hospitals could improve their scores, for example, by telling their doctors how to word events, such as how to describe an accidental puncture of a vein during surgery, so it won't show up in quality reports.
Such concerns aren't slowing the sprucing up of the nation's hospitals in search of a slice of almost $1 billion in bonuses. At the HCA hospital, the undercover CEO "was able to see things the way patients do," Jonathan Perlin, chief medical officer at Nashville, Tenn.-based HCA, said. "I can assure you every ceiling tile with a water stain got replaced."
nFlaws found in efforts to monitor, reward service.