Every day, thousands of patients receive a call or letter after being discharged from a US hospital. How was their stay? How clean and quiet was the room? How often have nurses and doctors treated them with courtesy and respect? The questions focus on what might be called standard customer satisfaction aspects of a medical stay, as hospitals increasingly see patients as consumers who may take their business elsewhere.
But other important questions are missing from these ubiquitous surveys, whose results affect how much hospitals are paid by insurers: They don’t survey whether patients have experienced discrimination during their treatment, a common complaint among diverse patient populations. Similarly, they fail to ask patients from diverse groups whether they received culturally appropriate care.
And some researchers say that’s a big oversight.
Kevin Nguyen, a health services researcher at Brown University School of Public Health, who analyzed data collected from government-mandated national surveys in new ways, found that — beneath the surface — they spoke to racial and ethnic disparities in care.
Digging deeper, Nguyen studied whether patients in a Medicaid managed-care plan from ethnic minority groups received the same care as their white peers. He examined four areas: access to essential care, access to a private doctor, timely access to checkups or routine care, and timely access to specialty care.
“It was pretty universal across races. So black beneficiaries; Asian American, Native Hawaiian, and Pacific Islander beneficiaries; and Hispanic or Latino or Latinx/Latino beneficiaries reported worse experiences across all four systems,” he said.
Nguyen says that customer evaluations of health care providers and systems surveys commonly used by hospitals can be more effective if they are able to go one level deeper — for example, asking why Getting timely care was more difficult, or why They don’t have private doctors — and if CMS doesn’t publicly release patient experience scores, it also shows how those scores vary by respondents’ race, ethnicity and preferred language. Such information can help discover whether a hospital or health insurance plan is meeting the needs of all rather than just some patients.
Nguyen did not study the reactions of LGBTQ+ people or, for example, whether people received worse care because they were obese.
The federal government requires the CAHPS survey for many health care facilities, and most acute care hospitals require the hospital version. Low scores can trigger financial penalties, and hospitals can reap financial rewards for improving scores or comparing to their peers.
The CAHPS Hospital Survey, known as HCAHPS, has been running for more than 15 years. Results are publicly reported by the Centers for Medicare and Medicaid Services to give patients a way to compare hospitals and to incentivize hospitals to improve care and services. Patient experience is the only thing that the federal government publicly measures; Readmissions and deaths from conditions including heart attacks and treatable surgical complications are among others.
Dr. Meena Sheshamani, director of the Centers for Medicare and Medicaid Services, said patients in the U.S. appear to be becoming more satisfied with their care: “We’ve seen significant improvements in HCAHPS scores over time,” she said in a written statement, citing, for example, the percentage of patients nationally who said that Their nurses “always” communicate well, up from 74% in 2009 to 81% in 2020.
But for as long as these surveys have been around, doubts have remained about what they actually capture. Patient experience surveys have become big business, with companies using marketing methods to boost scores. Researchers have questioned whether the emphasis on patient satisfaction — and the financial carrots and sticks tied to them — has led to better care. And they have long suspected that institutions can “teach the test” by training staff to respond to patients in a certain way.
National studies have found the link between patient satisfaction and health outcomes to be tenuous at best. Some more critical studies have concluded that “good ratings depend more on manipulable patient perceptions than good medicine,” citing evidence that health professionals were motivated to respond to patients’ requests rather than prioritize what was best from a care perspective, when they conflicted. was Hospitals have scripted how nurses should talk to patients to increase their satisfaction scores. For example, some were instructed to assure patients that their room was quiet by saying aloud, “I’m closing the door and turning off the lights to keep the hospital quiet at night.”
About a decade ago, Robert Wich-Maldonado, a health services researcher at the University of Alabama-Birmingham, helped develop a new module to add to the HCAHPS survey “dealing with topics such as experiences of discrimination, trust issues.” Specifically, it asks patients how often they’ve been treated unfairly because of race or ethnic characteristics, the type of health plan they have (or if they lack insurance), or how well they speak English. It asked patients if they felt they could trust their medical care providers. The goal, he said, was to report that data publicly, so patients could use it.
Some questions made it into an optional part of the HCAHPS survey — including how often staff were condescending or rude and how often patients felt staff cared about them as a person — but CMS doesn’t track how many hospitals use them. or how they use the results. And although HCAHPS asks respondents about their race, ethnicity and language spoken at home, CMS does not post that data on its public patient website, nor does it show how patients of different identities responded compared to others.
Without making extensive use of obvious questions about discrimination, Harvard School of Public Health Assistant Professor of Health Policy and Management Dr. Jose Figueroa doubts that the HCAHPS data alone “will tell you whether you have a racist system or not” — especially given the survey’s slumping response rate.
An exciting development, he says, lies in the emerging ability to analyze open-ended (rather than multiple-choice) responses through natural language processing, which uses artificial intelligence as an adjunct to analyze the sentiment that people express in written or spoken statements. In multiple-choice surveys.
A survey that analyzed hospital reviews on characteristics identified by Yelp that patients feel are important but not captured by HCAHPS questions — such as how caring and comforting staff members were and the billing experience. And a study this year in the Journal of Health Affairs used this method to find that providers at a medical center were more likely to use negative words when describing black patients than their white counterparts.
“It’s simple, but if used in the right way, can help health systems and hospitals understand whether they need to work on issues of racism within them,” Figueroa said.
Pres Ganey Associates, a company that pays a large number of US hospitals to conduct these surveys, is also exploring the idea. Dr. Tejal Gandhi leads a project there that aims to, among other things, use artificial intelligence to examine patients’ comments for signs of inequality.
“It’s still very early days,” Gandhi said. “With the epidemic and the social justice issues and all these things that have happened in the last few years, there’s just a lot of interest in this topic.”
Some hospitals, however, have taken the tried-and-true route to understanding how to better meet patients’ needs: talking to them.
Dr. Monica Federico, a pediatric pulmonologist at the Colorado School of Medicine and Children’s Hospital Colorado in Denver, started an asthma program at the hospital several years ago. About a fifth of its appointments proved to be no-shows. The team needed something more granular than patient satisfaction data to understand why.
“We identified patients who were in the hospital for asthma, and we called them, and we asked them, you know, ‘Hey, you have an appointment at the asthma clinic. Is there anything stopping you from coming?’ And we tried to understand what they are,” Federico said. At the time, he was one of the only Spanish-speaking providers in an area where pediatric asthma disproportionately affects Latino residents. (Patients also cited problems with transportation and inconvenient clinic hours.)
After making several changes, including extending clinic hours into the evening, the rate of no-show appointments has nearly halved.
CAHPS surveys are embedded in American health care culture and are likely here to stay. But CMS is now making tentative efforts to address issues previously overlooked in the survey: This summer, it is testing a question for a subset of patients 65 and older that will explicitly ask if someone visits a clinic, emergency room, or race, ethnicity, culture or The doctor’s office treated them in an “unfair or insensitive manner” because of characteristics including sexual orientation.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Along with policy analysis and polling, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). KFF is a non-profit organization that provides health information to the nation.
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