Section 2. Why Improve Patient Experience?
In the face of multiple priorities and limited resources, leaders of health care organizations may question the value of measuring and improving the patient's experience with care. Yet, powerful market and regulatory trends, combined with increasing evidence linking patient experience to important clinical and business outcomes, make a compelling case for improving patient experience as measured by CAHPS surveys.
Forces contributing to the growing imperative to improve patient experience include the public reporting of CAHPS survey scores as well as various initiatives to build measures of the patient experience into performance-based compensation systems, board certification and licensing, and practice recognition programs. A growing demand among patients for an enhanced service experience and greater participation in their health care is placing further pressure on health care systems to find ways to become more patient-centered.
Examples of prominent forces driving improvement efforts among health plans include the following:
- The Centers for Medicare & Medicaid Services (CMS) has been using several versions of the CAHPS Health Plan Survey since 1998 to measure the experiences of Medicare beneficiaries. These surveys are conducted annually with results reported publicly on the Medicare Plan Finder Web site. CAHPS survey results are combined with other quality measures in "star ratings" that take into account not only current levels of performance but also progress on improvement.
- The CAHPS Health Plan Survey is a mandatory part of health plan accreditation required by the National Committee for Quality Assurance (NCQA) for both commercial and Medicaid health plan product lines.
- A large number of States require the collection and reporting of the Medicaid version of the CAHPS Health Plan Survey as part of performance-based managed care contracts for Medicaid and Children's Health Insurance Program (CHIP) enrollees.
- Health plans offered in the new Federal and State-based Health Insurance Marketplaces will be required to conduct the Qualified Health Plan (QHP) Survey, which is a version of the CAHPS Health Plan Survey. Results of the survey will be incorporated into the "star ratings" for QHPs and may be publicly reported on Marketplace Web sites.
Examples of forces driving improvement efforts among medical groups and physician practices include the following:
- The Patient Protection and Affordable Care Act of 2010 includes several new provisions for measuring and reporting patient experience of care:
- Health systems choosing to participate in the Medicare Shared Savings Program are required to use the CAHPS Survey for Accountable Care Organizations (ACOs). The results of the ACO CAHPS Survey (which builds upon the CG-CAHPS core survey) are used for public reporting on the Physician Compare website, as well as for calculating any "shared savings" to be earned by participating ACOs.
- Similarly, the Physician Quality Reporting System (PQRS) program administered by CMS includes a patient experience survey component using the CAHPS for PQRS Survey, which also builds upon the CG-CAHPS core survey. Requirements for using this survey are being phased in over time; eventually, all medical practices with two or more eligible professionals will be required to measure and report patient experience using the PQRS CAHPS Survey. These survey results are reported on the Physician Compare Web site and used with other performance measures to adjust Medicare fee-for-service (FFS) payments to all participating physicians by 2017.
- Starting in 2019, two new physician payment programs—a merit-based incentive payment system (MIPS) and eligible alternative payment models (APMs)—are likely to include some version of the CG-CAHPS Survey as part of the quality measurement formula used for payment. These programs were created under the Medicare Access and CHIP Reauthorization Act (MACRA).
- The National Committee for Quality Assurance's (NCQA) Patient-Centered Medical Home program includes optional recognition of patient experience. Physician practices seeking recognition are encouraged to use the CAHPS Clinician & Group Survey with the Patient-Centered Medical Home Item Set.
- Virtually all of the sixteen State and community-based multistakeholder organizations funded under the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) program included the measurement, reporting, and improvement of patient experience with primary care in their efforts to reform their local health care systems. While the AF4Q program concluded in 2015, many of these collaborative organizations are continuing their survey efforts, as are other regional collaboratives participating in the Network for Regional Healthcare Improvement (NRHI).
- The American Board of Medical Specialties (ABMS), which oversees the Maintenance of Certification (MOC) process that 24 medical specialties use to confirm physicians' qualifications every five years, continues to explore requiring medical boards to use patient experience measures to assess the communication skills and professionalism of physicians with direct patient care responsibilities.
- The National Priorities Partnership has articulated a goal of measuring and using patient experience in all care settings. Its Work Group on Patient and Family Engagement has specifically identified widespread implementation of the CAHPS Clinician & Group Survey in ambulatory settings as a top priority.
- Health plans (such as Blue Cross Blue Shield of Massachusetts and HealthPlus of Michigan) and multi-stakeholder organizations (such as California's Integrated Healthcare Association) are incorporating patient experience scores into provider pay-for-performance incentives.
Improving patient experience has an inherent value to patients and families and is therefore an important outcome in its own right. But good patient experience also is associated with important clinical processes and outcomes. For example:
- At both the practice and individual provider levels, patient experience positively correlates to processes of care for both prevention and disease management.1 For example, diabetic patients demonstrate greater self-management skills and quality of life when they report positive interactions with their providers.2
- Patients' experiences with care, particularly communication with providers, correlate with adherence to medical advice and treatment plans.3-6 This is especially true among patients with chronic conditions, where a strong commitment from patients to work with their providers is essential for achieving positive results.7
- Patients with better care experiences often have better health outcomes.8, 9 For example, studies of patients hospitalized for heart attack showed that patients with more positive reports about their experiences with care had better health outcomes a year after discharge.10, 11
Measures of patient experience also can reveal important system problems, such as delays in returning test results and gaps in communication that may have broad implications for clinical quality, safety, and efficiency.
Patient experience is correlated with key financial indicators, making it good for business as well as for patients. For example:
- Good patient experience is associated with lower medical malpractice risk.12, 13 A 2009 study found that for each drop in patient-reported scores along a five-step scale of "very good" to "very poor," the likelihood of a provider being named in a malpractice suit increased by 21.7 percent.14
- Efforts to improve patient experience also result in greater employee satisfaction, reducing turnover. Improving the experience of patients and families requires improving work processes and systems that enable clinicians and staff to provide more effective care. A focused endeavor to improve patient experience at one hospital resulted in a 4.7 percent reduction in employee turnover.15
- Patients keep or change providers based upon experience. Relationship quality is a major predictor of patient loyalty; one study found patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician's practice than patients with the highest-quality relationships.16
- Sequist TD, Schneider EC, Anastario M, et al. Quality monitoring of physicians: Linking patients' experiences of care to clinical quality and outcomes. J Gen Intern Med 2008;23(11):1784–90.
- Greenfield S, Kaplan HS, Ware JE Jr, et al. Patients' participation in medical care: Effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3:448-57.
- DiMatteo, MR. Enhancing patient adherence to medical recommendations. JAMA 1994;271(1):79-83.
- DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians' characteristics influence patients' adherence to medical treatment: Results from the Medical Outcomes Study. Health Psychol 1993;12(2):93-102.
- Safran DG, Taira DA, Rogers WH, et al. Linking primary care performance to outcomes of care. J Fam Pract 1998;47(3):213-20.
- Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: A meta-analysis. Med Care 2009;47(8):826-834.
- Beach MC, Keruly J, Moore RD. Is the quality of the patient-provider relationship associated with better adherence and health outcomes for patients with HIV? J Gen Intern Med 2006;21(6):661-5.
- Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med 1985;102(4):520-8.
- Stewart MA. Effective physician-patient communication and health outcomes: A review. CMAJ 1995;152(9):1423-33.
- Fremont AM, Clearly PD, Hargraves JL, et al. Patient-centered processes of care and long-term outcomes of acute myocardial infarction. J Gen Intern Med 2001;14:800-8.
- Meterko M, Wright S, Lin H, et al. Mortality among patients with acute myocardial infarction: The influences of patient-centered care and evidence-based medicine. Health Serv Res 2010 Oct;45(5):1188-204.
- Levinson W, Roter DL, Mullooly JP, et al. Physician-patient communication: The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;277:553-9.
- Hickson GBC, Clayton EW, Entman SS, et al. Obstetricians' prior malpractice experience and patients' satisfaction with care. JAMA 1994;272:1583-7.
- Fullam F, Garman AN, Johnson TJ, et al. The use of patient satisfaction surveys and alternate coding procedures to predict malpractice risk. Med Care 2009 May;47(5):1-7.
- Rave N, Geyer M, Reeder B, et al. Radical systems change: Innovative strategies to improve patient satisfaction. J Ambul Care Manage 2003;26(2):159-74.
- Safran DG, Montgomery JE, Chang H, et al. Switching doctors: Predictors of voluntary disenrollment from a primary physician’s practice. J Fam Pract 2001;50(2):130-6.
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