Last week Ontario Minister of Health Eric Hoskins finally allowed the Local Health Integration Networks (LHINs) to release their implementation strategies on Primary Care Reform (the North Simcoe Muskoka one is under the October 2015 Report). Interestingly, the release of these documents, which Hoskins received on October 9, comes weeks after he released a document asking people for advice on how to implement Primary Care Reform. So essentially he asked for advice, after developing an implementation strategy.
Between this, and other documents released recently, one of the benchmarks that Dr. Hoskins would like to study is patient satisfaction. There are various metrics that he's proposed, including ability to access family physicians within 48 hours, and of course how satisfied patients are with their care. This is all part of wanting health care to be more "patient centred."
Intuitively this appears to make a great deal of sense. One would think that if you have a better health-care outcome, you're going to have more satisfied patients. Somewhat surprisingly, however, real world data around this very topic shows that the opposite, is in fact, true.
The Atlantic recently published an in depth review of how patients satisfaction scores affect care. As part of the so-called Obamacare reforms, one per cent of hospital budgets were retained by the government, pending outcome of patient satisfaction scores, and 30 per cent of Medicare funding is based on patient satisfaction surveys. The Centre for Medicare and Medicaid reasonably wrote, "Delivery of high-quality, patient-centered care requires us to carefully consider the patient's experience in the hospital inpatient setting." This sounds exactly like something out of Hoskins' speech book.
So what happened? Hospital Administrators moved to optimize the financial situation at their hospitals (reasonable, as that's their job). Physicians and nursing staff of course, wanted to ensure the health care goals of their patients. Since time immemorial, these two goals have often clashed. Under patient centred care, these two goals have begun to clash in surprising ways, some completely unexpected.
It appears that resources started being dedicated towards doing things that make patients happy, as opposed to providing for little things like, you know, their health care. The most off-the-wall example listed in the article was when a hospital realized the patients were unhappy with the quality of the food (resulting in lower patient satisfaction scores). They dedicated resources to asking nurses to present the food better, rather then, you know, improving the quality of the food itself!
As one of my colleagues half-jokingly suggested, if you want high satisfaction scores on Urology wards (where patients are predominantly men over 50), just replace the nurses with waitresses from Hooters. The medication dispensing and treatments will be all wrong, but the patient satisfaction rates will surely skyrocket.
Openly referred to as a "Disney" approach to health care, the goal seems to be maximizing the financial benefits of high patients scores. Unfortunately this comes at the cost of diverting resources from patient care, with unexpected end results. I was personally shocked to see that hospitals that have a higher patient satisfaction score, had a 12 per cent higher re-admission rate, nine per cent higher average patient cost and 26 per cent higher DEATH rate! Think about that for a minute. What is it essentially means that these hospitals spent so much time doing little things, like presenting food properly, to make patients feel happy, that they didn't have enough time to spend on providing actual medical care. The results were that the patients suffered as a result of this philosophy.
It also seems that this is not just the case of hospital care, but also for outpatient care. Antibiotic over prescription is a big problem across the world. It has led to the development of more and more resistant bacteria, and has led to the rise of the "superbug." It is therefore important for physicians to only prescribe antibiotics when absolutely necessary. Yet, a recent British Journal of General Practice study reveals that physicians who prescribed fewer antibiotics, had their patient satisfaction scores fall by up to six percentile points.
So essentially, those that were doing the right thing, were having their scores affected negatively, because patients didn't get what they wanted.
None of this is to say of course that there shouldn't be any checks or balances, or any accountability. Health-care spending in Ontario is something on the order of $50 billion per year. It is precisely because of a lack of accountability in government spending that we've had so many health-care scandals under the current government.
However, perhaps, rather than focus on touchy-feely items, designed to perpetuate a political agenda, we should look at accountability of health-care dollars for things that really matter.
Let's look at how quickly people are able to get joint replacement surgery. Let's look at how well patients are able to access palliative care at the end of their lives. Let's look at how quickly people can get cataract surgery. Let's check whether patients are able to access appropriate counseling for their diabetes (which is one of the highest cost diseases out there).
Oh, you mean if we did that it would expose just how badly underfunded those particular areas are? At a time when we want to create MORE management (which will be needed to review patient satisfaction surveys). Gee, I wonder why Eric Hoskins doesn't want to study real outcomes.
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