In this episode, Maria Miranda, Director of Emerging Payment Models and Meliza Weiner, Clinical Review Nurse at BESLER Consulting, discuss the impact of patient satisfaction on alternative payment models.
Michael Passanante: Hi, this is Mike Passanante. Welcome back to the Hospital Finance Podcast.
Today, I’m joined by Meliza Weiner, RN who is a clinical nurse manager here at BESLER Consulting. And I’m also joined by Maria Miranda who is the director of emerging payment models at BESLERConsulting.
Meliza and Maria have joined us today to explore the impact of patient satisfaction on alternative payment models.
Welcome to the show, both of you.
Maria Miranda: Thank you, Mike.
Meliza Weiner: Thank you.
Mike: So Maria, I’ll turn to you first. Can you explain to us why patient satisfaction is more important today than it was even four or five years ago?
Maria: Sure, Mike. So patient satisfaction has always had an impact on a provider’s business and bottom line because the patients’ perception of your facility can keep them away, but chances are it won’t keep them away forever.
It would probably take a serious incident to make you not go to your local hospital in an emergency or to make you drive across town to another facility.
I like to think of it like your cable company, for example. In my town, I only have a choice of two cable companies. I don’t know too many people who actually love their cable company. And when you call, you get bounced back and forth. And chances are you wait about 45 minutes before you even get a live body on the phone.
Having said that, if you have a choice in going to a facility for an elective procedure such as CJR or something not requiring you to be admitted, you might think twice.
So, for years, there’s been a push to increase patient satisfaction. Hospitals and providers of all types have taken these initiatives on themselves because they realize how important it is to keep their patients happy.
What we’re exploring today, however, is there’s been a change in the way that hospitals get paid. Patient satisfaction is now playing a direct role in how they get reimbursed.
Basically, the advent of bundled payments and other forms of value-add programs include satisfaction in their quality scoring. And that’s used to adjust their reimbursement.
So, going back to my cable company example, you might switch providers if you’re really frustrated, but the price that you pay for that service is not going to change by how happy you are with your cable company. Unlike the cable company, if you’re unhappy, your dissatisfaction will actually impact the hospital’s bottom line.
Mike: Meliza, turning to you, can you define patient-centered care and how that can impact the culture of an organization?
Meliza: So, back in 2015, the Institute of Medicine defined patient-centered care as “providing care that is respectful and responsive to individual patient preferences, needs and values that guides all the clinical decisions.”
In a nutshell, Mike, the patient has to be in the center of any care provided.
So, historically, healthcare organizational culture have always been created and led by healthcare professionals based on what is considered the best for patients—and rightfully so. But how about involving and considering what the patients think?
For example, pain management. Everyone’s pain tolerance is different. I, for instance, have a better pain tolerance than my husband, and he has a better pain tolerance than his friend. So, why assume that the same pain regimen would work?
Even if we had the same procedure like a total knee replacement, there are many factors to consider when it comes to pain management.
Another is patient education which are at times written in medical terminology that is understood only by healthcare team members and, most times, done on the day of discharge with their discharge instructions, even 30 minutes to 1 hour before the patient leaves.
This does not give enough time for the patient and the family to comprehend and ask questions.
A patient-centered healthcare organization makes the patients needs be in the front and center, especially when creating, designing and streamlining their processes and procedures as it relates to patient care and experience. All members of the healthcare organization, especially direct, hands-on care team members need to focus and tailor their efforts to meet the patient’s specific needs.
So, going back to my example earlier, asking the patient where they would like to be in the pain scale as far as pain relief and giving a patient time to ask questions about their health and treatment plan while providing education throughout their stay—or better yet, ask them how they would prefer to be educated. I myself learn visually. It would lead to an effective pain management and plan of care, a better overall perception of care, thus better patient satisfaction.
Mike: Maria, what role does patient satisfaction play in CMS’ new mandatory payment models?
Maria: So, Mike, as we’ve discussed several times before in prior podcasts, the HCAHPS (which is the patient satisfaction measure) is one of three measures that’s used to calculate the hospital’s total quality composite score for CJR. It’s also going to be used to calculate the quality composites score for the new EPM’s—for AMI, CABG and SHFFT.
So, using CJR as an example, HCAHPS is weighted at 40% of the total score. So, it could represent as much as eight points for the hospital.
Additionally, if the hospital’s HCAHPS national percentile for the period being measured at reconciliation is at least two deciles higher than it was the same period the prior year, the hospital will also get a 10% quality improvement bonus.
So, for example, if a CJR participating hospital got over the 92% for HCAHPS and the hospital only ranked at the 70th percentile for the same period in the prior year, then that hospital would not only get the eight quality points for their HCAHPS score, they’d get an additional 10% or 0.8 for quality improvement that gets added on.
The SHFFT Model will follow the same methodology as CJR, also weighting HCAHPS at 40% of the total score. AMI and CABG will each weight HCAHPS at 20% of the total score.
So, whether we’re talking 20% or 40%, it’s obvious that HCAHPS is going to be able to move the needle in calculating your total score and determining which level the hospital is going to fall into.
And we’ve discussed before as well that there are four different categories—excellent, good, acceptable and not acceptable. That’s also going to determine the hospital’s eligibility to even receive a reconciliation payment as well as it will determine the ultimate percentage discount that will be taken on their target price at reconciliation.
Mike: And Meliza, you’ve been frontline with patient care. Can you talk to us about some of the strategies that hospitals can implement to improve patient satisfaction?
Meliza: Well, sure, Mike! You would love to know that there are multiple strategies that healthcare organizations have planned and, better yet, have implemented already. I think the first thing is to find out what the patients are telling them.
Most healthcare organizations are using public reporting data (such as HCAHPS like what Maria had mentioned), patient surveys and patient rounding to gather feedback in order to strategize on the opportunities for improvement.
So, I’ll give you an example. If 90% of the patients are not satisfied with the call bell response, then that’s an opportunity for improvement.
The next move is to develop ways to fix it. For example, about the call bell, an improvement strategy could be to ensure that a call bell is answered in the first ring or no one passes a room with a call bell ringing. Some healthcare organizations call it the “no pass zone” or, better yet, be proactive in that before any team member leaves a patient room, make sure everything is done and ask if there’s anything else they would need.
There are numerous strategies, but what’s important here that we need to remember is to take into account what the patients are saying, what they’re thinking, what they’re feeling and expecting. In addition, any improvement strategy developed must be consistent and carried throughout the organization.
Mike: Is employee engagement important for patient experience?
Meliza: Absolutely! Definitely. There have been multiple studies—evidence-based research, surveys—that demonstrate how employee engagement affect the patient experience. Basically, an engaged employee is an employee who is aligned with the vision and mission of the healthcare organization, which encompasses excellent quality care, patient satisfaction and patient experience.
You see, Mike, when employees are engaged, they are empowered to ensure that the organization’s core values are delivered. Simply put, they will do everything they can in order to deliver the care and services to meet the organization’s goal, thus fulfilling its mission and vision.
Mike: Maria, I want to turn back to you. Can you help explain how data can improve patient satisfaction scores?
Maria: Sure! As we’ve been saying, the HCAHPS is monitored and reported on quarterly basis. It’s helpful for you to improve because it’s something that you can trend. It’s not real-time by any means, but it’s not so outdated that you can’t monitor the improvement. As opposed to the risk score that’s updated once a year, HCAHPS is quarterly.
So, the HCAHPS is broken out into several distinct categories, so it’s easy to drill down into the problem areas and make specific improvements. As with anything that’s measured, Mike, you can trend the data to see if you’re going in the right direction, and you can share that data and be completely transparent with everyone that’s involved.
Some hospitals say that how you collect the data can also make a difference. Some hospitals believe that they get more positive responses on their HCAHPS when the interaction is personal, via phone call or in-person because patients hesitate to give negative feedback to a live person. Or maybe their response won’t be as harsh as if they were just completing a form.
Mike: Maria, you mentioned HCAHPS, and we know that’s a commonly used measure for assessing patient satisfaction. What can you tell me about that measure?
Maria: So, with HCAHPS, there are 11 different items being measured. It’s important to understand how these data points are being used in the calculation and how much weight each one holds. It’s important to be as transparent as possible when trying to make improvements and share the data with everyone involved because, basically, you need total engagement and commitment in order to get that improvement.
So, I mentioned the 11 different items. There are seven that are considered composite measures. There are two individual items. And then, there are two global items.
For the purposes of CJR and other CMS bundles, the composite measures are weighted at 100% while the individual and global items are weighted at 50% to arrive the HCAHPS linear mean rollup score.
It’s important to note that as part of the final rule for EPM such as that came out in December, CMS removed the pain management composite measure from the calculation of the HCAHPS’ linear mean rollup score. This change will go into effect for performance year one of the CJR program. And it will be the method that’s used for the other EPMs as well.
Mike: I want to drill in on something you just said there. Why was pain management removed from the calculation of the linear mean score? You would think that’s an important factor in determining patient satisfaction.
Maria: Yeah, and it is. And while CMS believes that pain control is an important part of routine care, they want to avoid confusion about the appropriate use of the pain management dimension questions. They’re trying to balance that against the very real public health concern over the opioid epidemic. CMS does not believe that there’s any empirical evidence that shows that the lack of prescribing opioids actually reduces the HCAHPS survey scores.
So, to be clear, the pain management is still being measured. It’s still very much a part of HCAHPS. But in terms of these Episode Payment Models, that measure is being removed from the calculation.
Mike: Thanks for clearing that up, Maria.
Meliza, my last question is for you. How can a hospital or health system strike a balance between improving patient satisfaction scores and managing expenses?
Meliza: Well, Mike, it’s a misconception to think that spending more money is going to improve patient satisfaction. I think what is required is having organizational leaders engage their employees in a manner that helps the employees understand how their actions or inactions can have an impact on patient satisfaction, patient experience and the overall organizational goals which frankly includes finance.
So, for example, having the staff understand how not being responsive to the call bell will lead to a low patient satisfaction score which, in turn, affects the patient’s perception of care (or lack thereof), the patient’s likelihood to recommend, and thus, ultimately, affecting the organization’s reputation, their growth and reimbursement.
It all ties in one circle, Mike.
What needs to be understood is that finance is as an important aspect in a healthcare system like any other business company. So it is critical for not just the leaders to understand the financial impact of their operational management, but even the frontline employees need to understand how they affect the bottom line.
Mike: That’s great! Meliza and Maria, thanks for stopping by today and helping us understand more about patient satisfaction scores.
Meliza: Great! Thank you.
Maria: Thank you.