Do higher patient experience ratings yield better clinical outcomes?

Health Care Current | May 16, 2017

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory, and legislative changes.

My Take

Do higher patient experience ratings yield better clinical outcomes?

By Steve Burrill, Vice Chairman, US Health Care Providers Leader, Deloitte LLP

I lead a double life. On days when I’m not wearing a suit and tie and meeting with clients, I’m spending my weekends and holidays on our farm in Oregon – clad in a t-shirt, faded jeans, and work boots – where we raise certified organic lambs, chickens and eggs, and vegetables. Over the past several years, I’ve watched farming undergo a transformation. A new generation of farmers is responding to customers who want locally grown organic produce, and humanely raised, hormone-free meat. Farmers also grow nutritious foods that our customers aren’t familiar with, so we educate them...usually with great success.

Health care is undergoing a similar transformation where customers are helping drive change. Some hospitals are responding – and reaping better patient-experience scores and higher revenue. Last June, we reported that hospitals with high patient-satisfaction scores tend to be more profitable than lower-rated facilities. This association is strongest for aspects of patient experience most likely to be associated with better clinical care, particularly the patient’s interaction with nursing staff.

But that doesn’t tell us the full story. A patient might walk out of the hospital completely satisfied with the overall experience, despite not having received high-quality care.1 The second part of our analysis, which we released this week, explores the link between the patient experience and clinical care quality. The Deloitte Center for Health Solutions conducted regression analyses to examine the association between patient perceptions and a broad range of hospital quality measures – both process of care measures and clinical outcomes.

To examine the relationship between patient experience and hospital clinical quality, we combined hospital-level patient experience ratings from the most widely used hospital experience survey – the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) – with clinical outcome and process-of-care quality measures from the Centers for Medicare and Medicaid Services (CMS).

When rating a hospital experience, patients tend to focus on the tangible aspects of the visit, such as waiting times in the emergency room, or how quickly the nurse responds to the call button. Better communication with the staff, for example, might lead to fewer errors or a more personalized course of treatment. But those factors might not be related to the care the patient received. A doctor's skill and judgement, staff teamwork, and compliance with surgical protocols cannot be directly observed by an anaesthetized patient, for example, and cannot be accurately reflected by experience metrics.2

Hospitals turn their attention to improving customer experiences

While there can be costs involved in improving the patient experience, the investment could help boost clinical outcomes. Here’s a look at three hospitals that have altered their care processes in an effort to improve the patient experience:

  • Ohio-based Mercy Health rolled out bedside tablets with an in-house “MyChart” app at one of its hospitals. The app allowed patients to access their own data, including medication interaction information and test results. This helped reduce staff overload by decreasing the number of questions patients had for medical staff. It also helped patients regain a sense of control over their care, which ultimately improves their experience of care.3,4
  • Florida Hospital Tampa, part of the Adventist Health System, had one of the highest emergency department (ED) patient volumes in the region. Staff engagement and patient experience ratings were low. The hospital introduced a flexible patient flow strategy (Doc1stER) combining immediate bedding and team triage to reduce patient wait times. A year after the program’s implementation, patient ratings of ED doctors increased to the top 15th percentile, and the median door-to-provider ED wait time was reduced by 10 minutes, even as ED volume grew by 30 percent.
  • Wisconsin-based ThedaCare was one of the first health systems to implement a “collaborative-care” model to improve quality and patient experience, and reduce costs. Under this model, a bedside-care team is created for each patient (e.g., case physician, nurses, pharmacist, and a dedicated discharge planner). When a patient is admitted, the team analyzes the patient’s medical history, reviews the current diagnosis and potential complications, and anticipates a discharge date. The team then builds a coordinated plan of care and elicits input from patients and their family to develop a “single-care” plan, which is updated daily during “team huddles.” Clinical quality measures such as readmissions and mortality (from pneumonia) have improved by more than 40 percent, and patient experience scores increased by 50 percent.5

Many farmers, like hospitals, have recently begun to place more emphasis on the customer experience. Patient-experience scores might not always or fully reflect hospital care quality, just as not all farms grow high-quality and nutritious foods. Some farms produce fruits and vegetables that look gorgeous and have incredibly long shelf-lives, but shoppers might discover the blemish-free vegetables they bought don’t have much flavor despite their outward appearance.

Results of our most recent analysis indicate a strong correlation between the patient experience and hospital quality, even after controlling for hospital and local area characteristics. Our findings suggest that investments in patient experience and quality can be mutually reinforcing strategies for hospitals.

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1 Alexandra Robbins, The Atlantic, “The Problem with satisfied patients,” April 17, 2015,
2 Theresa Weldring and Sheree M.S. Smith, “Patient-Reported Outcomes (PROs) and Patient-Reported Outcome Measures (PROMs)”, Health Serv Insights, 2013; 6: 61–68, doi: 10.4137/HSI.S11093
5 Health Affairs, “The Triple Aim: Care, Health, And Cost,” May 2008

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In the News

Senate confirms Gottlieb, amends FDA user fee package

Last week, the Senate confirmed Scott Gottlieb, MD, as Commissioner of the US Food and Drug Administration (FDA). Gottlieb previously served as Deputy Commissioner of the FDA under President George W. Bush. His résumé also includes almost two decades working as an advisor and consultant on the boards of various pharmaceutical drug companies.

As FDA Commissioner, Gottlieb will oversee product safety and approvals for all of the FDA’s product centers, including biologic and biosimilar products, pharmaceuticals, radiological health products, and medical devices. He will also oversee the implementation of the 21st Century Cures Act – legislation designed to revamp the US biomedical innovation industry (see the Deloitte analysis 21st Century Cures and life sciences innovation). Gottlieb said his first priority as FDA Commissioner will be to address the opioid epidemic by supporting the development of non-addictive alternative painkillers and new medical treatments for opioid use disorders.

Gottlieb has expressed support for the publication of complete response papers, FDA documents that cover why the agency did not approve a new product. No rules address making complete response papers public. Some analysts say releasing them could help manufacturers understand agency thinking, leading to fewer redundancies in getting through the FDA’s approval pathways.

The biomedical industry expressed support for Gottlieb’s confirmation. The Biotechnology Innovation Organization (BIO) published a statement crediting his extensive qualifications to lead the agency, and the California Life Sciences Association congratulated Gottlieb on his appointment.

Related: At a markup on May 11, the Senate Committee on Health, Education, Labor and Pensions (HELP) voted to advance the FDA user fee reauthorization package to the Senate floor. The package, which includes the Prescription Drug User Fee Act (PDUFA) and accompanying amendments for generic drugs (GDUFA), medical devices (MDUFA), and biosimilar products (BsUFA), will expire in September 2017 without reauthorization. The HELP Committee held two previous hearings on the agreements, during which senators supported a quick reauthorization process for the package (see the April 11, 2017 Health Care Current).

In the markup, senators added two amendments to the legislations:

  • Deadlines to review generic drug applications: This amendment, offered by Senator Susan Collins, requires the FDA to review abbreviated new drug applications (ANDAs), which are applications for new generic drugs when a branded reference product already exists in the market, within three months of the application’s submission if fewer than four approved drugs are available.
  • Review clinical trial standards: Offered by Senator Orrin Hatch, this amendment directs the Secretary of the Department of Health and Human Services (HHS) to convene a public meeting to review inclusion and exclusion standards for clinical trial participants. The amendment directs the HHS Secretary to work with industry stakeholders, physicians, and patient advocates to discuss and report on alternative clinical trial designs that may include populations traditionally excluded from clinical trials.

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New CCIIO director is overseeing exchanges

Last week, the administration announced that Randy Pate would become the new director of the Center for Consumer Information and Insurance Oversight (CCIIO). CCIIO is the office of CMS that oversees provisions of the Affordable Care Act (ACA), including the public health insurance exchanges.

Pate comes to CCIIO from Health Care Service Corporation, a customer-owned health insurer operating Blue Cross and Blue Shield plans, where he served as the vice president of public policy. Before that, Pate was a health policy fellow at the Heritage Foundation. Jeff Wu, deputy director for policy at CCIIO, served as acting director until the new director was named.

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Veterans Health Administration requests increased flexibility for telemedicine licensing

The Veterans Health Administration (VHA) requested increased flexibility in telemedicine licensing rules at a recent hearing with the Senate Appropriations Committee. According to the VHA, allowing Veterans Administration (VA) health care providers to conduct remote consultations, regardless of state licensure, will improve access to care for veterans and offset access limitations from specialist shortages in remote areas. Specifically, the VHA requested that Congress invoke the Constitution’s “Supremacy Clause” to allow the VHA to supersede state licensing policies.

States authorize medical licensing in their borders (including licenses for physicians to practice telemedicine). While the VHA has the authority to connect physicians at any VHA facility with any patient, that patient must be inside a VHA clinic. A patient may not use telemedicine tools to connect with physicians outside the same state from their home, a private clinic, or another place where the patient may access the internet, such as a public library or an academic setting.

Veterans with rare diseases, chronic conditions, and who need continuous care even as they move could benefit from more flexible telemedicine rules, according to the VHA.

Representative Glenn Thompson and Senator Joni Ernst introduced bills in the House and the Senate, the Veterans E-Health and Telemedicine Support Act of 2017 (the VETS Act), that would allow qualified VHA physicians to operate across state lines to provide telemedicine services, regardless of the setting of care. The bill would also require HHS Secretary Tom Price to review telemedicine use and policies in the VHA, and report the VHA’s progress in telemedicine use to Congress.

Background: The VHA is a leader in using telehealth services, investing $1.2 billion in 2016 in telehealth, and provided more than 2 million telehealth appointments. About 12 percent of VHA’s patients received some telehealth services, according to the administration. The administration has committed to increase this percentage.

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Regional extension centers serve a key role in EHR and health IT implementation

Regional extension centers are helping clinicians implement provisions of the Medicare Access and CHIP Reauthorization Act (MACRA). Some of these extension centers are working to help clinicians improve quality and reduce costs to succeed under the Merit-based Incentive Payment System (MIPS).

Regional extension centers were established by the Office of the National Coordinator (ONC) for Health Information Technology (health IT) to help physicians and providers implement electronic health records (EHRs) under the Meaningful Use program. Regional extension centers helped with key EHR implementation issues, such as vendor selection and workflow analysis. ONC funded 62 regional extension centers to assist small and or rural physician practices implement EHRs and become EHR meaningful users.

Many regional extension centers have partnered with state agencies to help clinicians with IT issues, including those called for by MACRA. The Georgia Health IT Extension Center, for example, partnered with the state to help Medicaid-eligible providers who are also in the MIPS program. The center is also helping with data sharing and offering direct technical assistance.

Analysis: Deloitte’s Survey of US Physicians found that many physicians are not ready to implement MACRA. In 2016, the survey determined that many physicians are unaware of MACRA or how it will affect their practices. Regional extension centers are bridging the gap between providers, value-based payment models, consolidation, and health IT. They are playing a key role in EHR and health IT implementation.

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DSRIP programs to address social determinants of health

States and hospitals are using Delivery System Reform Incentive Payment (DSRIP) programs to improve quality of care and reduce costs for low-income populations, according to the National Academy for State Health Policy (NASHP). Under 1115 Waivers, hospitals can use DSRIP payments in Medicaid to partner with non-hospital providers to develop infrastructure or implement care transformation. Providers earn incentive payments for exceeding state-based performance improvement measures.

DSRIP programs aim to improve population health by using flexible funding and engaging community-based organizations to address social determinants of health. DSRIP programs also promote alternative payment models in managed care.

Thirteen states have approved DSRIP programs. Some examples of what they are doing include:

Population health: Some DSRIP agreements offer providers incentive payments for meeting specific population health measures. In New York, for example, providers receive incentive payments if they promote mental health, reduce premature births, or prevent substance abuse, chronic diseases, or sexually-transmitted diseases.

Social determinants of health: Massachusetts allows Accountable Care Organizations (ACOs) to use DSRIP funds to address social determinants of health, such as domestic violence. Under its DSRIP, Washington state requires Accountable Community of Health (ACH) to address the social determinants of health for the regional population.

(Source: Kartika and Rosenthal, “Using DSRIP to improve population health,” NASHP, May 2017)

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OIG: CMS should implement new tools to prevent hospitals from gaming quality reporting

CMS met regulatory standards to verify its inpatient quality reporting (IQR) system, but the agency’s approach does not go far enough to identify hospitals’ gaming of quality reporting, according to a new report from the HHS Office of the Inspector General (OIG).

While 99 percent of the hospitals CMS reviewed passed validation, and CMS took appropriate action on all hospitals that failed the review, the OIG reported that the sample of hospitals that CMS reviewed may have been skewed. For example, CMS does not target hospitals with abnormal data patterns in their review sample. According to the report, targeting hospitals with outlying data patterns for additional review could identify inaccurate or false reporting and support Medicare program integrity.

According to the OIG, CMS did not use analytic tools that could help the agency identify hospitals that are outliers on particular measures (e.g., a hospital with very high or low values on a measure as compared to similar hospitals) and include them in the targeted sample for validation. In fact, none of the 49 hospitals in the targeted sample were selected due to abnormal reporting patterns. Instead, CMS selected hospitals that missed or had limited participation in their IQR data.

Given the findings, the OIG is recommending that CMS use data analytic tools to identify hospitals whose IQR data is significantly different from other comparable hospitals to target for an additional review process. According to the report, CMS concurred with this conclusion.

Background: For this report the OIG analyzed CMS review data for the 2016 payment year. OIG reviewed why CMS selected specific hospitals for review, how many hospitals were selected, and the outcomes of those reviews. Additionally, the OIG further interviewed both hospital and administrative leadership on ways to improve the review methodology. CMS reviewed 400 randomly selected hospitals, and 49 targeted hospitals for potential violations of IQR reporting requirements. Of the 449 hospitals that CMS reviewed, only six failed the review. CMS then reduced their Medicare payments by 0.6 percent for the 2017 plan year.

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Breaking Boundaries

Targeting overuse, low-value health care

Recognizing that more is not always better health care, five years ago, the American Board of Internal Medicine Foundation and Consumer Reports launched the Choosing Wisely initiative to curb overuse of unnecessary and potentially harmful services. The goal of this initiative is to improve health care value for patients, and reduce harm and costs. The initiative began with about nine medical specialty societies, including the American College of Physicians, the American College of Cardiology, and the American College of Radiology.

The effort has since grown to more than a dozen specialty societies identifying nearly 500 common medical tests and procedures that might not have clear benefits for patients and should sometimes be avoided. Consumer Reports developed patient-friendly educational materials, and providers can take advantage of a suite of education modules to help them engage in these discussions with patients. Choosing Wisely aims to encourage discussions and shared decision-making between clinicians and patients by helping patients choose care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary

The results are in – and they show the potential to save costs and improve outcomes through targeting overuse: After five years, results are starting to show the initiative has made a difference in targeting overuse of unnecessary and low-value health care. A recent article in Health Affairs indicates that Choosing Wisely has resulted in a small reduction in low-value imaging for back pain. Back pain is common and costly, both to the health care system and to patients in terms of out-of-pocket costs. Harvard Medical School in Boston compared commercial insurance claims filed two years before the Choosing Wisely campaign, to claims filed two years after. It found that low-value imaging – including X-rays, computed tomography, and magnetic resonance imaging – fell four percent.

The five largest health systems in California have integrated Choosing Wisely into their systems and have released some early results as well. Cedars-Sinai incorporated almost 100 Choosing Wisely recommendations into their electronic health records, and found that physicians who followed all of the prompts had patients with fewer medical complications and who left the hospital sooner. When physicians fully followed the recommendations, costs dropped by hundreds of dollars per patient encounter. As a whole, the hospital reported a $6 million dollar drop in health care spend over the first full year. The University of Southern California Medical Center and the University of California Los Angeles aimed to integrate the recommendations around low-value preoperative care such as blood tests and electrocardiograms for cataract surgery patients. Results are showing that the reduced testing freed up staff, and provided six months of additional good vision to patients by shortening their wait time for surgery.

The Sharp Rees-Stealy Medical Group in San Diego gave out wallet cards to patients listing “5 Questions to Ask Your Doctor” before getting any test, treatment, or procedure, as well as engaging community skilled nursing homes with the initiative. This group saw a 10 percent decrease in opioid prescribing in one year, and a five percent drop in unnecessary cardiac stress tests. Sutter Health in Northern California addressed more than 130 of the recommendations, and engaged more than 3,000 clinicians treating one million patients in Choosing Wisely efforts. Their work yielded a $66 million drop in spend since 2010, by avoiding unnecessary tests and treatments. Repeat labs have also dropped by 20 percent.

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