Abstract
Patient experience metrics are increasingly the focus of value-based incentive programs by both the federal government and private payers. A clear financial imperative exists to improve experience; at the same time, it is becoming evident that engaging patients in their care also leads to better clinical outcomes.
For the first time, the US Department of Health & Human Services (HHS) has established goals for value-based payment programs in the United States. HHS plans to link 85% of Medicare fee-for-service care to value by 2016, and 90% by 2018. In addition, HHS has a goal to tie 30% of Medicare payments to value through alternative payment models by 2016, and 50% by 2018 [1]. Value can be defined as the health outcomes achieved per dollar spent [2]. Outcomes in health care are a measure of the quality of care. There are many indicators of quality in health care. Timely access, effective use of evidence-based interventions, and avoidance of safety events such as infections are just a few of the indicators used to measure quality in health care.
While the federal value-based payment reform programs include a variety of quality indicators, a significant component of these programs are measures of patient experience. In fact, in Medicare's Hospital Value-Based Purchasing program, 25% of the total score for hospitals is tied to performance on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience survey. Similarly, for ambulatory physician practices participating in the Medicare Shared Savings Program (MSSP), 24% of the quality indicators are tied to the Clinician and Group Consumer Assessment of Healthcare Providers and Systems patient experience survey. It is evident that the federal government sees patient experiences as a measure of value in health care.
Why Does Patient Experience Need to Be Considered as Part of Value in Health Care?
Consumerism
Public reporting requirements foster transparency of health care quality data, and as the number of Americans with mobile phones continues to grow, access to health care information is available at consumers' fingertips. This is true even in rural markets, where 87% of adults have cell phones, and 52% have smart phones [3]. This enables consumers to make informed decisions about where to receive their care, just as they use public information to make decisions about where to go for car repairs or which hotel to book. It is estimated that 17% of consumers consult online sources for reviews of doctors or other health care providers [4]. Consumers are looking for speed, affordability, and convenience of health care services as they take on more of the burden to pay for health care with rising copayments and high-deductible insurance plans.
Ratings and Rankings
The ease of access to publicly reported patient experience and other quality data has led to a proliferation of health care ratings and rankings. These rating and ranking systems use publicly available data to inform various methods for calculating lists of the best or worst hospitals, home health agencies, and nursing homes. The latest of these is the proposed Medicare quality star rating system. In this system, Medicare uses a sophisticated statistical process to combine various types of publicly reported health care data, including patient experience, to derive a 5-star rating for hospitals across the country. Because hospitals of different sizes may not publicly report every indicator used in this rating system, Hospital A's star rating will be based on one set of data, and Hospital B's star rating will be based on a related but different set of data. The required HCAHPS patient experience survey has a 22% weighting in the Medicare star rating system.
How Does Patient Experience Affect Value?
In 2001, the Institute of Medicine (IOM) of the National Academies outlined a set of dimensions that denote a quality patient experience. The IOM said an exceptional experience is one that is safe, timely, efficient, effective, equitable, and patient-centered [5]. Patient centeredness as defined by the IOM is care that is centered on individual patient needs, preferences, and values. It is logical that care that is more patient-centered would result in better outcomes. The literature supports this conclusion. In a review by Price and colleagues, better patient experience is associated with better adherence to recommended treatment, better clinical and patient safety outcomes, and lower utilization [4]. A similar conclusion was drawn in a descriptive paper by Cosgrove and coauthors, which outlined methods used by a variety of high-performing health care organizations to improve patient centeredness as a key strategy to lower costs and improve quality. This paper emphasized the importance of engaging and empowering patients as partners in their care to achieve better outcomes and better value [6].
As part of an overall approach to measuring experience, health care organizations can consider the 6 dimensions noted by the IOM and choose indicators in each category as part of a comprehensive approach to measurement (See Table 1). The patient-centered dimension is measured using standard, validated patient experience surveys (See Table 2). These surveys are required by Medicare as part of quality reporting for inpatient hospitals and for ambulatory practices enrolled in the MSSP. Questions in both of these patient experience surveys focus on communication, timeliness, understanding of medications, care transitions, and treatment follow-up. Using data from the experience surveys in addition to clinical and safety data provides an organization with an understanding of the totality of the experience from the patient and family perspective.
Dimensions of Patient Experience and Example Indicators
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Questions
Conclusion
Patient experience is being measured and reported as part of payment reform initiatives by both the federal government and other payers. These programs consider patient experience as a measure of health care quality, along with clinical and patient safety indicators. These indicators are publicly reported and are used by other third parties in rating and ranking systems. Increasingly, consumers are using this readily available information about patient experience, quality, and safety to make decisions about where to receive high-value health care.
Patient and community engagement will continue to be high-leverage strategies as we continue to evolve in the era of population health. Assuring an exceptional experience means arming people with skills, knowledge, and confidence to participate as fully informed partners in their own care, and this leads to better health outcomes and lower cost of care—the very definition of value.
Acknowledgments
Potential conflicts of interest. J.D.W. has no relevant conflicts of interest.
- ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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