This is an expanded version of the article that appears in print.
In the constantly evolving health care environment, patient satisfaction seems to be making its way to center stage, whether it involves hospital surveys or online patient reviews on sites such as Yelp.com. Moreover, patient satisfaction has become a key quality indicator closely tied to Medicare reimbursement rates. These developments are creating new challenges for ophthalmologists.
“While patient satisfaction is clearly very important, this movement can have unintended consequences for patient care,” noted Robert M. Kinast, MD, of the Devers Eye Institute in Portland, Ore. “In most industries, satisfaction equals success, but patient satisfaction and quality health care are not always the same thing. In fact, overemphasis on patient satisfaction may actually worsen health outcomes.”
As Dr. Kinast pointed out, the most patient-satisfying option may not be the best medical decision. For example, a patient may want an antibiotic for viral conjunctivitis or narcotics for dry eye symptoms. “Likewise, a sound medical decision—like taking away a driving license due to vision impair-ment—may not be satisfying,” he said.
The growing role of patient satisfaction in the health care industry reflects how the definition and measurement of quality of care has evolved. William L. Rich III, MD, who serves as medical director of health policy at the Academy, has been on the front lines of these changes for more than two decades.
Early guidelines. Dr. Rich explained that a landmark study published in 19881 described an evidence-based Resource-Based Relative Value Scale (RBRVS) for physicians’ services, which lawmakers later used as a reimbursement tool for physicians. Since the author could not at the time identify the metrics to include patient value and quality, the elements he used to construct the RBRVS involved “measuring the work [intraservice work] of performing medical services and procedures, estimating preservice and postservice work, comparing work across specialties, measuring practice costs, extrapolating from surveyed services, and establishing an RBRVS for evaluation/management services and for invasive procedures.”1
Current metrics. Over time, the RBRVS guidelines have evolved into a comprehensive definition of quality of care based on several components, Dr. Rich said. “These include process measures—for example, did the physician follow normative care patterns?—and outcomes measures—for example, how did one’s diabetic patient population compare to a national database?”
Two other components are also included. The first is patient-reported outcomes. These involve the individual’s quality of life and are measured with National Institutes of Health–validated tools, including Patient Reported Outcomes Measurements (PROMs). Dr. Rich noted that the Academy was one of the first medical societies to create a measurement tool for patient-reported outcomes. “Measure 303: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery” is an outcomes measure based on a pre- and postoperative visual function survey.
The second component is patient satisfaction data, which are measured with both informal surveys and validated tools.
One concern among ophthalmologists is that patient satisfaction surveys are not scientifically based, but that is rapidly changing, Dr. Rich said. He added that ophthalmologists who perform surgery at surgery centers may be familiar with the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS), a standardized questionnaire for adults developed by the American College of Surgeons and other specialty societies to evaluate patients’ satisfaction regarding care with the surgical intervention.
For ophthalmologists, the value provided by these validated instruments that measure patient satisfaction extends beyond reimbursement rates and promotional considerations. “Patient satisfaction is not just a marketing tool,” said Dr. Rich. “There is good evidence that patient satisfaction impacts physician confidence, and that leads to better outcomes. In addition, if patients are confident in their physicians, they are more likely to adhere to prescriptions for drug therapy, eyedrops, and other long-term treatments.”
The Yelp Conundrum
Dr. Kinast sees the value in a strong patient satisfaction movement, but he also has concerns about these metrics being tied to reimbursement rates, as well as the unintended consequences of prioritizing this movement. “Measuring health care quality is challenging. I am concerned that even standardized patient satisfaction surveys do not represent an accurate, statistically valid assessment of physician health care skills,” he said.
Patients’ perceptions. Dr. Kinast’s interest in the topic stems from his research into which factors patients considered when commenting on their physicians on the online review site Yelp.com.
In a pilot study presented at an Association for Research in Vision and Ophthalmology meeting, Dr. Kinast found that patient satisfaction scores on Yelp did not correlate with ophthalmologists’ surgical complication rates or peer reviews.2 “We didn’t have a large enough sample size to publish our data, but it sparked our interest in this disconnect,” he said.
Dr. Kinast waited for a few years until more patient satisfaction reviews on Yelp were available and performed a content analysis. He searched Yelp.com for all patient reviews of San Francisco ophthalmologists from October 2004 to August 2012. Each comment was placed in one of nine categories divided into two topic areas. The physician categories included 1) physician interpersonal manner, 2) physician technical competence, and 3) general physician perceptions. The office categories included 1) office staff, 2) office wait time, 3) office access/availability, 4) office environment, 5) office finances/cost, and 6) office location.
His team’s findings, published in Ophthalmology,3 showed that half of the comments were not about the physician’s skills but rather involved nonphysician office factors. Even more significant, Dr. Kinast said, “threequarters of the negative comments were nonphysician factors, and these negative comments can harshly impact a physician’s reputation.” Satisfaction stemmed from the entire experience at the physician’s office, not just physician interactions.
“Improving physician-patient communication is a straightforward and important strategy to increase patient satisfaction,” said Dr. Kinast. “However, many other factors besides communication skills increase patient satisfaction, and some can be harmful. Numerous studies indicate that a collective focus on satisfaction can worsen health outcomes at high costs.”
Dr. Kinast cited a prospective study4 in which higher patient satisfaction was associated with increased overall health care expenditures, prescription drug costs, inpatient stays, and even mortality rates. “Providing more tests and medicine increased patient satisfaction without improving quality of care,” he said. “Likewise, patient satisfaction has been found to not correlate with other Medicare performance-based outcome measurements, like metrics of surgical quality.”5
He added, “Like any business, if we delegate more resources to satisfaction, we’ll improve our satisfaction scores. But I’m concerned from a public health perspective. These resources will satisfy patients in the short term and improve physician reputations and profit health care practices, but at what cost? If these resources cost our health care system more without improving health outcomes—actually worsening outcomes—is it worth it?”
Dr. Rich said he agreed with Dr. Kinast that patient satisfaction alone is not an acceptable metric for quality but should be augmented by measures of process, outcomes, and patient-reported outcomes. “The Academy PQRS cataract measure group includes levels of final vision, patient-reported outcomes, rate of return to the operating room within 30 days [a measure of significant complications], and patient satisfaction,” he said.
How Ophthalmology Rates
Across medicine. When it comes to patient satisfaction, ophthalmologists have unique advantages, Dr. Rich pointed out. “We provide care that dramatically improves the patient’s quality of life,” he said. “Cataract surgery is a great example of how we enhance vision with a low incidence of blinding infection. In addition, where we once had no treatment for macular degeneration, now there are interventions that can save vision. This translates into patient satisfaction.”
In addition, Dr. Kinast noted that patient satisfaction surveys may affect ophthalmologists less than physicians who practice in other fields. For instance, those who practice in settings such as emergency rooms and pain clinics must deal with patients who are seeking pain medications and are quick to complain when they aren’t accommodated.
Moreover, many ophthalmology patients are substantially more involved in their own care. For example, in his subspecialty (glaucoma), the decision-making process is naturally patient centered, which can empower patients and improve satisfaction.
Within ophthalmology. Dr. Kinast’s research has turned up some nuances within ophthalmology. He cited a study that he conducted comparing ophthalmology subspecialties, which he presented at an American Society of Cataract and Refractive Surgeons meeting.6 Refractive surgeons had significantly more reviews and higher patient satisfaction scores than other ophthalmic specialties.
“I think the differences involve superb visual outcomes, [the self-selected] patient population, and an innate focus on quality customer service,” Dr. Kinast said. “Refractive practices have traditionally emphasized patient satisfaction, and they’ve done a tremendous job.”
Value of Feedback
Although criticism can be challenging to accept and may carry some tough lessons, it can be valuable. As Dr. Rich pointed out, patient satisfaction scores can help identify any underlying weaknesses in how ophthalmologists are running their offices. “The hardest job in private and academic medicine is the person at the front desk who is answering the phones and greeting patients,” he said. “In our practice, we are constantly surveying people who call the office to determine how they were treated by the office staff. The feedback is powerful.”
And Paul P. Lee, MD, JD, said, “Patient satisfaction by reported standardized measures is helpful in informing us how well we are taking care of patients. It is one part [of many] of the assessments being used by patients, payers, and employers to assess performance.”
What patients want. Dr. Lee, who is at the University of Michigan, has a long-standing interest in the topic of patient satisfaction and expectations for care. He has published an article looking at the use of a standardized patient satisfaction questionnaire to assess quality of care provided by ophthalmology residents.7 The questionnaire measured the residents’ technical ability, interpersonal manner, communication, and professionalism; results indicated that patients had a high level of satisfaction with the care they received.
In his work, Dr. Lee has found that patients care deeply about the physician-patient relationship. “The key component in patient satisfaction is to have a relationship that works the best for the physician and patient. There needs to be mutual trust and respect and a communication style that fits both parties,” Dr. Lee said. “Establishing this trust will lead to better quality-of-life outcomes, which in turn impacts patient satisfaction perceptions.”
1 Hsiao WC et al. JAMA.1988;260(16):2347-2353.
2 Kinast RM, Day SH. Concordance of internet and peer reviews for ophthalmologists in San Francisco. Poster A568 presented at: Association for Research in Vision and Ophthalmology Annual Meeting; May 4, 2010; Fort Lauderdale, Fla.
3 Kinast RM et al. Ophthalmology. 2014;121(9):1843-1845.
4 Fenton JJ et al. Arch Intern Med. 2012;172(5):405-411.
5 Lyu H et al. JAMA Surg. 2013;148(4):362-367.
6 Kinast RM et al. Online reviews of ophthalmologists compared by subspecialty. Paper presented at: American Society of Cataract and Refractive Surgeons Annual Meeting; April 2014; Boston.
7 Jagadeesan R et al. Ophthalmology. 2008;115(4):738-743.
Robert M. Kinast, MD, is the associate fellowship director in glaucoma at the Devers Eye Institute in Portland, Ore. Financial disclosure: None. Paul P. Lee, MD, JD, is professor of ophthalmology, director of the Kellogg Eye Center, and chairman of the Department of Ophthalmology and Visual Sciences at the University of Michigan in Ann Arbor. Financial disclosure: None. William L. Rich III, MD, is medical director of health policy at the Academy and in practice with Northern Virginia Ophthalmology Associates in Fairfax, Va. Financial disclosure: None.