Opinion: How government surveys could harm patients

Alexander Blood and Jacquelyn Corley

Perhaps the greatest evolution in the modern doctor-patient relationship has been the shift away from the traditional doctor-centric model to a more patient-focused approach — one that emphasizes patient autonomy, shared decision-making, and holistic treatments.

But, in an effort to give more power to patients, some health care providers have embraced policies that may actually put the patients they’ve sworn to protect at risk.

In support of the relatively new model emphasizing patient-centered care, the Centers for Medicare and Medicaid Services created a scoring system called the Hospital Consumer Assessment of Healthcare Providers and Systems to evaluate and standardize patient satisfaction.

The HCHAPS survey is comprised of questions that assess communication and responsiveness of the health care team, as well as the comfort of the environment on the ward. Not only is this survey gaining influence and changing the way medicine is taught and practiced, it is also affecting the way doctors and hospitals are paid.

In 2005, the Deficit Reduction Act mandated the reporting of hospitals’ HCAHPS scores in order to receive complete Medicare reimbursements. Further, with the establishment of the Affordable Care Act in 2010, hospital performance, as measured by HCAHPS scores, became the basis of the Hospital VBP Program, a payment system that accounts for the largest share of Medicare spending.

Providers and hospitals should always strive for better patient care, but implementation of HCAHPS does not necessarily correlate with better health outcomes. Doctors might avoid treating patients with complex health conditions that could affect score ratings. And focusing too much on these metrics could force the hand of providers to deliver substandard care in an attempt to satisfy patient demands.

The system incentivizes health care providers to overorder, overdiagnose, and overprescribe — with no concrete improvement in health outcomes. The Choosing Wisely Campaign released a study in 2014 which demonstrates that in a given week, 72 percent of the physicians surveyed ordered at least one unnecessary test or procedure, often in order to appease patient demands.

It seems there is no definitive conclusion regarding the utility of patient satisfaction scores and health outcomes. We should all strive for patient-centered care and preservation of patient dignity via a multidisciplinary and team-based approach. However, as doctors, sometimes we need to bring components into the health care equation that may not be preferred by patients but are necessary for safe and effective practice.

For example, all patients admitted to the neurology unit can attest to the unpleasant experience of being woken up in the middle of the night for an assessment. But these processes are necessary to detect new complications as early as possible so that lifesaving treatment may be delivered.

Physicians must prioritize resources toward better medical care and not simply toward patient comfort — which is unfortunately the main theme of the HCAHPS survey. Doctors are not perfect, and this perpetual challenge has existed for years to find balance between patient autonomy and maintaining high standards for therapeutic responsibility.

After all, it was described long ago in the lines of the Hippocratic Oath that every doctor swears with a hand over heart: “I will apply, for the benefit of the sick, all measures (that) are required, avoiding those twin traps of overtreatment and therapeutic nihilism.”

Jacquelyn Corley, M.D., is a neurological surgery resident at Duke University Medical Center. Alexander Blood, M.D., is an Internal Medicine resident at Duke University Medical Center.