The Washington PostDemocracy Dies in Darkness

Hospital ratings often depend more on nice rooms than on health care


As research findings go, this was a Holy Yikes. A study of 50,000 patients throughout the United States showed that those who were the most satisfied with their care (the top quartile) were 26 percent more likely to be dead six months later than patients who gave lower ratings to their care.

The study, “The Cost of Satisfaction,” appeared in JAMA Internal Medicine.

Oh, the irony. The most satisfied patients not only died in greater numbers but racked up higher costs along the way. Plus, health-care providers receiving the top satisfaction scores were rewarded with higher reimbursements by the Centers for Medicare and Medicaid Services (CMS), which administers the patient survey.

Lead author Joshua Fenton, a professor of family medicine at the University of California at Davis, had set out to measure the relationship between patient satisfaction and hospital resource use, drawing on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Ultimately, his research raised questions about whether CMS is dangerously off target in collecting patient satisfaction data to drive health-care improvements.

That was 2012. More research published this year by two sociologists likewise found that a patient’s hospital recommendation had almost no correlation to the quality of medical care received or patient survival rate. The researchers looked at CMS hospital data and patient surveys at more than 3,000 U.S. hospitals over three years. The hospitals where fewer patients died had only a two percentage point edge in patient satisfaction over the others.

What’s going on? Cristobal Young, associate professor of sociology at Cornell University and lead author of the study, calls it “the halo effect of hospitality.” Young found that what mattered most to patients in ratings were the compassion of nurses and amenities like good food and quiet rooms. It’s why hospital managers are being recruited from the service industry and we’re seeing greeters in the lobby and premium TV channels in rooms, he says.

Patients tend to value what they see and understand, but that can be limited, Young continues. They give hospitals good cleanliness ratings when they observe waste baskets are emptied and sheets are changed. “They can’t see a virus or tell you how clean the room is in ways that matter,” he says.

Similarly, patients can tell you if a physician communicates well. But most people do not have the medical skills to assess whether a physician provided the appropriate diagnostic test or made suitable recommendations, Fenton says.

In his study, patients receiving more medical interventions, treatments and hospitalizations were more satisfied with their experience. Yet, after adjusting the 26 percent mortality rate of the satisfied patients with data about their baseline health and comorbidities, their death rate soared to 44 percent over the patients who weren’t as happy with their care.

One possible explanation is that every surgery, procedure or medication carries the potential to leave you worse off. While a patient may perceive that more aggressive treatment is better, “overtreatment” can hasten death, too.

There is a more insidious reason satisfied patients did not track with better medical outcomes, though. The majority of hospitals and medical practices today are rewarded with higher compensation, promotions, bonuses or increased CMS reimbursements for attaining high patient satisfaction scores. The twist is that the path to keeping patients happy can run counter to best medical practices.

A patient may give an unfavorable rating to a physician who refuses to write an unsafe opioid prescription or order an unwarranted CT scan. A doctor may not bring up a patient’s obesity or cognitive impairment to avoid the person’s ire on a survey later.

In a 2014 study of 155 physicians by the University of Wisconsin-Madison’s School of Medicine and Public Health, close to half said that pressure to please patients led to inappropriate care including unnecessary tests and procedures, hospital admissions, and opioid or antibiotic prescriptions.

“Time after time, studies show that physicians who accede to patient requests have higher patient satisfaction,” Terence Myckatyn and co-authors wrote in a 2017 article exploring how patient satisfaction scores affect medical practice. Keeping patients happy is not always the best strategy for patient wellness or physicians, however, says Myckatyn, a plastic and reconstructive surgeon at Washington University School of Medicine.

“Directly tying financials to surveys as a metric to evaluate physicians can be shortsighted and unfair. It’s a difficult calculus,” says Myckatyn, stressing that patient surveys should be only one measure in the toolbox for assessing health-care providers.

CMS posts patient satisfaction data on its Hospital Compare website along with medical statistics about surgery complications, infection rates and mortality. But it’s the hotel-like amenities that seem to drive ratings, so that’s where many hospitals have invested, Young says.

He points to the new $2 billion Stanford Hospital in Palo Alto that offers private patient rooms, each with a 55” television and iPad so patients can stream Net­flix, order a burger from the cafeteria, or video conference with family. This is how hospitals are competing with each other in a consumer market where medical quality indicators can take a back seat, he says.

Whether the 29-question HCAHPS survey has led to better medical care, Fenton credits public surveys for keeping hospitals and physicians accountable for treating patients with respect and dignity. What he objects to is the harm done by conflating patient satisfaction with the technical quality of medical care.

Likewise, Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association (AHA), sees patient satisfaction and medical outcomes as apples and oranges. They are each important and don’t have to correlate. In addition, whether a nurse responds quickly to a call button is not just about hospitality, Foster maintains in reference to Young’s study.

“If a patient needs to use the restroom and a nurse doesn’t arrive in a timely fashion, patients [who go on their own] can fall,” she says. “[The nurse’s responsiveness] becomes a crucial clinical outcome issue.”

Akin Demehin, AHA’s director of policy, also believes patient surveys have a place in improving medical care. “Patients have unique insights that only they are in a position to convey,” Demehin says.

Several hospitals were able to reduce their readmission rates after taking a close look at patient comments regarding problems in care coordination and hospital discharge, he says.

Collecting patient feedback began its ascent in 1985 when Press Ganey Associates introduced a survey to measure health-care provider performance. Ten thousand medical institutions today still use it. By 2006, CMS was distributing the HCAHPS survey to randomly selected patients around the country.

Once the Internet exploded, consumer-driven health care was out of the gate. Online ratings for restaurants, electronics, and the patient experience became “part of our modern day currency,” says physician Raina Merchant, director of the Center for Digital Health at the University of Pennsylvania Perelman School of Medicine and associate vice president at Penn Medicine.

Merchant studied the impact of patient ratings on Yelp and found they were strikingly parallel to HCAHPS results. The significant difference, she says, is that Yelp reviews cover a broader range of concerns than standard surveys. You’ll find more detailed patient-to-patient information about billing, comfort care, medical costs and the experience of family caregivers, for instance.

Health-care providers “miss an opportunity to learn about consumers if they don’t pay attention to social media,” says Merchant, who sees online reviews as “democratizing.”

Will covid-19 change how we rate physicians and hospitals? “Think about how much we spend on the health-care system in the U.S. Then when we need basic things like swabs [to test for coronavirus] we don’t have them,” says Young, “. . . or nurses and doctors straining to have [personal protective equipment].”

“It’s mind-boggling,” he says. “Maybe the coronavirus will help reprioritize everyone’s thinking about medical quality. Nobody is thinking about how nice their [hospital room] views are anymore.”

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