whopper

Former jolly good fellow
15+ Year Member
Feb 8, 2004
6,893
1,671
Visit site
Status
Attending Physician
The ACA has a provision that has patients rating their care.
Okay, sounds fine.
The reimbursement the hospital receives is tied to the patient satisfaction.

Okay, WAIT!, cough cough, hold on there!

Does that mean our units with involuntarily patients will receive far less reimbursement? (Yes-if you didn't know, involuntary patients don't want to be in the hospital Sherlock and aren't expected to give their treatment team high marks). Will those people that come to the ER demanding Xanax and not getting it will lead to less reimbursement when teh responsible ER doc or psychaitrist says no? Will this create an incentive for doctors to give out meds of abuse inappropriately?

I don't know.

http://thehealthcareblog.com/blog/2012/10/26/patient-satisfaction-the-new-rules-of-engagement/

estimated to place at risk an average of $500,000 to $850,000 annually per hospital
http://www.hcahpsonline.org/home.aspx

If anyone does know please inform me given that I didn't read the entire ACA.
 

OldPsychDoc

Senior Curmudgeon
Moderator Emeritus
10+ Year Member
Dec 2, 2004
6,240
3,864
57
Left of Center
Status
Attending Physician
There are already a lot of efforts (predating ACA) to somehow link payment to performance/quality. This is why Quality Improvement is more and more a feature of all residency programs, is being emphasized in the infamous CLER visits that are coming out as part of program and hospital accreditation, and is called out as "Performance in Practice" (PIP) in the Maintenance of Certification process. This is all going to happen even if the Republicans take over the country, repeal the ACA in its entirety, and institute some sort of capitalist healthcare utopia.

I happen to work for an organization that is a bit ahead of the curve on some of this stuff, and probably what you need to realize is that in a well-managed healthcare system it will not come down to "Medicare says that you had too many poor reviews, so you're fired!" More realistically, a finite percentage of compensation is "at risk", and it is tied to a specific measurement that you and your colleagues agree upon ahead of time--e.g. a goal % of patients that "Strongly Agree" that they were "Treated with Respect" during their visit, based on a standardized survey, or perhaps that your unit meets a benchmark of % discharges before noon. Again, a well-managed system recognizes that when you're working with a bunch of highly impaired psychotic patients, "Patient Satisfaction" means something completely different, and we adjust our quality metrics to reflect meaningful measures.
 
OP
whopper

whopper

Former jolly good fellow
15+ Year Member
Feb 8, 2004
6,893
1,671
Visit site
Status
Attending Physician
My last year of residency, a similar approach was attempted by the GME tying X-Mas bonuses to patient satisfaction and was presented to all of the chief residents. The ER chief and I brought up the same arguments. Our two fields probably had the most to lose from this new approach, however well-intentioned, with residents losing pay because they were doing the right thing such as doing a 72-hold on a patient.

So I asked just how intelligent this method was. Did it take into account that in ER and psychiatry, patient satisfaction often times comes 2nd, 3rd, possibly even at no place compared to other issues such as safety of the patient and the community, following appropriate guidelines for enforcing parens patriae, and denying drug abusers their hit of Xanax? The GME people admitted they didn't take these into consideration, ignoring that patient satisfaction doesn't always equate with better treatment, and then told us they were putting this approach on hold because they saw some validity in our concerns.

I recall telling all the residents about this. One of the residents sarcastically and jokingly said, "dammit, I want my Christmas bonus! For now on everyone gets as much Xanax as they want!" (He was joking. He was a good resident and I knew he would never do that).

So the question I got is, will the ACA be rather 2 dimensional in reimbursement, or does it take into account that in medicine, sometimes doing the right thing isn't keeping the patient happy such as with involuntarily hospitalization?

Again, a well-managed system recognizes that when you're working with a bunch of highly impaired psychotic patients, "
So will the ACA be "well managed" in this regard?
 
Last edited:

F0nzie

5+ Year Member
Aug 22, 2011
1,621
1,226
Status
Attending Physician
Not sure why patient satisfaction with doctors needs to be regulated. Anybody can file a complaint or go to another doctor. This just seems like an unnecessary cost to the already high cost of delivering healthcare.
 

Shikima

10+ Year Member
Oct 15, 2006
4,529
2,650
Status
Attending Physician
It's all unnecessary with concerns to Government "excess" and "oversight". Teh Fonz is correct.
 
OP
whopper

whopper

Former jolly good fellow
15+ Year Member
Feb 8, 2004
6,893
1,671
Visit site
Status
Attending Physician
I talked to some people in the University that I figured would not (edit: meant to write "know") more about this. I was told by several staff members that the ACA patient satisfaction issue was brought up because psychiatry is very different in this regard vs the other fields.

I was told that psychiatry is exempt from the satisfaction surveys, though there is debate to start them sooner or later with psychiatry. I was also told that this issue was very much on the top of the heads of several hospitals and is likely a known issue with the lawmakers that drafted the ACA given that psychiatry was given an exception.

Okay, that's a relief...for now. Anyone find anything else let us know.
 
Last edited:

OldPsychDoc

Senior Curmudgeon
Moderator Emeritus
10+ Year Member
Dec 2, 2004
6,240
3,864
57
Left of Center
Status
Attending Physician
More on the subject...
Again, not so much a function of the ACA as it is of the Corporatization (or in my opinion, the Dilbertification) of Medicine.
 
OP
whopper

whopper

Former jolly good fellow
15+ Year Member
Feb 8, 2004
6,893
1,671
Visit site
Status
Attending Physician
Medicine is an incredible economic mystery in terms of making a fair system to pay for it. Capitalism works great for things like hot dogs. It doesn't work well for healthcare. Several people through no fault of their own have serious health problems. On the other than you got human nature. It too doesn't work well for healthcare. How many people that are overweight actually consider that a major liability and major risk for upping their need for cash to pay for future problems and inability to work? Very few, until it's too late.

Seems to me no matter what system you put in there'll be problems. It's complicated.
 

kugel

10+ Year Member
7+ Year Member
Feb 6, 2007
826
16
Status
Attending Physician
My county's psych hospital began handing out satisfaction surveys to all inpts a few years ago. They did actually help identify problems and likely solutions to some issues. However, when the ratings came back as 87% overall "satisfied" (for a pt pop'n 60% involuntary), I began to ask questions. Turns out only about 30% of the surveys issued were ever returned. When I asked how those missing surveys were accounted, the answer was that they are not. There was no attempt to reconcile where they went, if employees were trashing them, if most of the pt's who were unsatisfied do not turn one in, etc. As expected, there no interest in finding out what happened to them or what 70% missing surveys might mean.
 

Therapist4Chnge

Neuropsych Ninja Faculty
Moderator Emeritus
10+ Year Member
Oct 7, 2006
21,515
2,482
The Beach
Status
Psychologist
If you want something done…make the gov't require it.
If you want something done right….find and pay the best people for the given job.

Hint: They aren't gov't employees or the hospital employees who hand out the cards to every patient.
 

masterofmonkeys

Angy Old Man
10+ Year Member
7+ Year Member
Sep 9, 2008
1,582
255
Status
Attending Physician
Patient satisfaction surveys make about as much sense as asking 8th graders what they think of their Algebra teacher. This is such a massive violation of some very basic tenets of psychology, informational theory, and economics that it's not even funny. The fact that people even thought this made sense is evidence that 1) No physicians were involved and 2) It's all idiots, all the way down.

I don't do benzos. I tell people things they don't want to hear like 'you don't have bipolar, you have mood reactivity/instability and the best treatment for that is individual therapy.' I tell people they need to lose weight and pills aren't going to 'fix' it. I tell them things they don't want to hear, I tell them to do things they don't want to do. That's my job. I'm a freaking physician. And you're going to penalize me for doing my job well?

As for QI the same exact criticism applies. Often times the 'markers of quality' we choose make little to no sense and either penalize physicians for patient lifestyle choices, or put them into an unwinnable box.

Classic example that's affected my family's income over the years is the VA using number of patients with HTN on HCTZ as a quality of care marker. In my mother's clinical experience, and a growing body of research, HCTZ is not particularly benign especially in an elderly population or a population at risk of falls. Because she uses her clinical judgment and decides broken hips and SDHs are bad, she makes less money.

But my current favorite is tying quality of care to A1C. WTF? An estimated 90% of DM2 cases are COMPLETELY DERIVED BY LIFESTYLE CHOICES. I should know, my large extended family went from NO diabetics 30 years ago to MOSTLY diabetics today. So a disease that's mostly (MOSTLY) caused by lifestyle choices, and then mostly dependent on patients' lifestyle choices afterward, is going to be a marker of how good I am as a physician?

It's honestly scary to me that more of us aren't more up in arms not about anything political about ACA, but how it structurally attempts to undercut and undermine physicians, first blaming us for things out of our control, then punishing us for being good doctors, then to add insult to injury trying to tell us how to practice.
 

TexasPhysician

Moderator
10+ Year Member
Sep 1, 2008
4,769
1,941
Status
Attending Physician
See Press-Ganey and how it affects ER Rx writing.

It is a horrible idea, but it is being pushed at many hospitals. My hospital has recently done them for quality improvement, but I have yet to see truly constructive criticism provided.

I can not provide an answer as it relates to the ACA. I'm not sure even the writers of the ACA quite understand it all yet.
 

sunlioness

Fierce. Proud. Strong
10+ Year Member
Feb 23, 2007
1,535
766
Status
Attending Physician
An email went out today saying that for 2015, any physician who achieves 90th percentile or better on patient satisfaction will get a $10K bonus.

I really really wanted to "reply-all" that email with, "SWEET!!! Who wants some Adderall??!!" But I restrained myself.
 

Ibid

Posting total rubbish
5+ Year Member
Jun 21, 2010
747
28
There are already a lot of efforts (predating ACA) to somehow link payment to performance/quality. This is why Quality Improvement is more and more a feature of all residency programs, is being emphasized in the infamous CLER visits that are coming out as part of program and hospital accreditation, and is called out as "Performance in Practice" (PIP) in the Maintenance of Certification process. This is all going to happen even if the Republicans take over the country, repeal the ACA in its entirety, and institute some sort of capitalist healthcare utopia.

I happen to work for an organization that is a bit ahead of the curve on some of this stuff, and probably what you need to realize is that in a well-managed healthcare system it will not come down to "Medicare says that you had too many poor reviews, so you're fired!" More realistically, a finite percentage of compensation is "at risk", and it is tied to a specific measurement that you and your colleagues agree upon ahead of time--e.g. a goal % of patients that "Strongly Agree" that they were "Treated with Respect" during their visit, based on a standardized survey, or perhaps that your unit meets a benchmark of % discharges before noon. Again, a well-managed system recognizes that when you're working with a bunch of highly impaired psychotic patients, "Patient Satisfaction" means something completely different, and we adjust our quality metrics to reflect meaningful measures.
Also "psychotic" patients wont be taking the option to fill in the forms or use an ipad to fill in a form..... they are going to do it after an episode if at all where they will be in as good a position as anyone to say if they were treated with respect and so on...

In the UK a certain percentage of providers income is at risk.... a very tiny part... based on Patient Reported Outcome Measures..... which in mental health are things like how in control of your life are you and so on.... all introduced by a Tory (right wing) government running a socialised health care system....

Mountains out of molehills most of the objections to this kind of stuff imo
 

Ibid

Posting total rubbish
5+ Year Member
Jun 21, 2010
747
28
My county's psych hospital began handing out satisfaction surveys to all inpts a few years ago. They did actually help identify problems and likely solutions to some issues. However, when the ratings came back as 87% overall "satisfied" (for a pt pop'n 60% involuntary), I began to ask questions. Turns out only about 30% of the surveys issued were ever returned. When I asked how those missing surveys were accounted, the answer was that they are not. There was no attempt to reconcile where they went, if employees were trashing them, if most of the pt's who were unsatisfied do not turn one in, etc. As expected, there no interest in finding out what happened to them or what 70% missing surveys might mean.
In the UK their are targets for the percentage of returns, which are lower in mental health, and then the onus is to find creative ways to elicit what can be useful information...

Also the emphasis is on finding things that can be improved on and doing that rather than just getting a good return...

Another win for socialised medicine! Where everyone can just use their intelligence for the benefit of patients and the bottom line comes in second.... second place where it belongs.
 

sunlioness

Fierce. Proud. Strong
10+ Year Member
Feb 23, 2007
1,535
766
Status
Attending Physician
10% of our salary is withheld for various reasons. 5% for institutional goals and 5% for goals set by the department. 2.5% of the institutional goals is patient satisfaction, but they gave up trying to measure that for mental health. They just assume we all meet it. I think the surveys still go out, but they don't count? The other 2.5% is having a certain percentage of charts closed within a certain percent of time (reasonably attained without too much effort. If I don't dictate and close quickly, I forget what we talked about anyway). The other 5% right now is linked to attendance at department meetings.

The thing alluded to above is an actual bonus. $10K for 90th percentile. $5K for 75th.

I mean, I guess it's a nice thing they're doing. And goodness knows, I'd like the money. But not at the expense of my clinical judgment. Now I know it's not always at the expense of my clinical judgment. I listen. I validate. I make eye contact. I take the time to answer questions. I'm nice. But still . . . how people fill out their surveys and who decides to fill out their surveys, that's out of my control.

I always fill out my surveys and give my PCP perfect 5s. I'm not sure she's that stellar, but certain not deserving of having her salary docked just because I don't like her. (Assuming I didn't like her. I like her fine. She's just not the best one I've ever had and we've disagreed on some things that I know I'm right about. ;) )
 

Ibid

Posting total rubbish
5+ Year Member
Jun 21, 2010
747
28
An email went out today saying that for 2015, any physician who achieves 90th percentile or better on patient satisfaction will get a $10K bonus.

I really really wanted to "reply-all" that email with, "SWEET!!! Who wants some Adderall??!!" But I restrained myself.
and their I was thinking that capitalism with all its focus on financial incentives was perfect.....

In all honesty this is just a brilliant example of why private money should be kept out of health care..... it actually leads to perversity....
 

Ibid

Posting total rubbish
5+ Year Member
Jun 21, 2010
747
28
10% of our salary is withheld for various reasons. 5% for institutional goals and 5% for goals set by the department. 2.5% of the institutional goals is patient satisfaction, but they gave up trying to measure that for mental health. They just assume we all meet it. I think the surveys still go out, but they don't count? The other 2.5% is having a certain percentage of charts closed within a certain percent of time (reasonably attained without too much effort. If I don't dictate and close quickly, I forget what we talked about anyway). The other 5% right now is linked to attendance at department meetings.

The thing alluded to above is an actual bonus. $10K for 90th percentile. $5K for 75th.

I mean, I guess it's a nice thing they're doing. And goodness knows, I'd like the money. But not at the expense of my clinical judgment. Now I know it's not always at the expense of my clinical judgment. I listen. I validate. I make eye contact. I take the time to answer questions. I'm nice. But still . . . how people fill out their surveys and who decides to fill out their surveys, that's out of my control.

I always fill out my surveys and give my PCP perfect 5s. I'm not sure she's that stellar, but certain not deserving of having her salary docked just because I don't like her. (Assuming I didn't like her. I like her fine. She's just not the best one I've ever had and we've disagreed on some things that I know I'm right about. ;) )
Thats all wrong.... wrong wrong....wrong.

Its the whole organisation and teams that should be judged...... financial penalties should lie with the organisation.... if the organisation does well then everyone from the doctors to the people who clean the wards and empty the bins should share in the reward... imo
 

OldPsychDoc

Senior Curmudgeon
Moderator Emeritus
10+ Year Member
Dec 2, 2004
6,240
3,864
57
Left of Center
Status
Attending Physician
  • Like
Reactions: sunlioness

Ceke2002

Purveyor of Strange
7+ Year Member
Sep 26, 2009
5,762
4,810
Melbourne
Status
Other Health Professions Student
What I don't understand is why you even need patient satisfaction surveys in the first place to ensure standards of care are being met? I mean shouldn't any half way decent medical practitioner and/or healthcare centre be striving for constant improvement, especially in line with medical developments and better understanding of diverse patient populations, of their own accord without big brother breathing down their necks with Press Ganey this, and HCAHPS that, and so on. Granted the clinic I attend does do random patient satisfaction surveys themselves, but it's a teaching clinic and the surveys are used to improve training methods and provide students with feedback.

Not to mention 'patient satisfaction' and 'did clinician so and so perform their duties as a practitioner to the best of their abilities and in line with accepted evidenced based best practice recommendations' are not necessarily one and the same thing. I'm just thinking of some of the 'patient satisfaction' feedback my own Psychiatrist would get from some of his more difficult patients - let's see, there's the non engaging eating disorder patient that spends the majority of sessions yelling abuse at him; the patient who has difficulty with the concept of boundaries and has needed to be pulled into line for abusing email privileges; the recent floridly manic bipolar patient that made leering threats of sexual violence against a student he was supervising. He's an excellent Doctor/Therapist, but depending on who you actually ask he could very well be the devil incarnate himself, so how does that help improve services, like at all, ever?

Sense, this makes none. o_O
 

OldPsychDoc

Senior Curmudgeon
Moderator Emeritus
10+ Year Member
Dec 2, 2004
6,240
3,864
57
Left of Center
Status
Attending Physician
  • Like
Reactions: Ceke2002
OP
whopper

whopper

Former jolly good fellow
15+ Year Member
Feb 8, 2004
6,893
1,671
Visit site
Status
Attending Physician
When I was in Cincinnati the talk was that psychiatry was exempt from the patient satisfaction surveys.

But we had a lecture at St. Louis U, and the announcement is that psychiatry is not exempt. What are other people hearing at their institutions?
 

Ceke2002

Purveyor of Strange
7+ Year Member
Sep 26, 2009
5,762
4,810
Melbourne
Status
Other Health Professions Student
You're likely better off on your side of the Pacific...
Not if our current Government continues with it's attempts at slashing funding to pretty much everything we won't be. Thankfully most of the BS they're trying to pass through the Senate has been blocked or defeated (or they've backed off in the face of immense opposition), but I think right now pretty much everyone down under is going 'So when exactly IS the next election' so we can vote these imbeciles out. I know our current Government has called for some sort of audit into the mental health system to make it more 'efficient', which if I recall last time they were in power basically translated to 'oh ****, I think we broke it'. :rolleyes:
 
Mar 24, 2014
4,393
3,840
Rural Area Medical Facilty
Status
Psychologist
When I was in Cincinnati the talk was that psychiatry was exempt from the patient satisfaction surveys.

But we had a lecture at St. Louis U, and the announcement is that psychiatry is not exempt. What are other people hearing at their institutions?
At our institution we are going to target diabetes and depression. It means a couple of checks in the medical record to show that the doc looked at the feet and the patient filled out a two item depression screen. As a psychologist, I cringe at the implementation of these "interventions" without any type of research methodology being utilized. We have no idea if any of this will have any bearing on any real outcome measure and we are not comparing it to anything either. Of course, the ACA doesn't pay for an expert to design a quality care program so it defaults to someone with a business degree to implement this and it ends up being a checkbox in the CMR. As a psychologist, I have the skill set and also some experience with program development but I can't bill for it so there is no way that I can devote the time necessary for this and the hospital won't hire someone to do it either.
 

heyjack70

Junior Member
10+ Year Member
7+ Year Member
Nov 24, 2005
745
247
Status
At our institution we are going to target diabetes and depression. It means a couple of checks in the medical record to show that the doc looked at the feet and the patient filled out a two item depression screen. As a psychologist, I cringe at the implementation of these "interventions" without any type of research methodology being utilized. We have no idea if any of this will have any bearing on any real outcome measure and we are not comparing it to anything either. Of course, the ACA doesn't pay for an expert to design a quality care program so it defaults to someone with a business degree to implement this and it ends up being a checkbox in the CMR. As a psychologist, I have the skill set and also some experience with program development but I can't bill for it so there is no way that I can devote the time necessary for this and the hospital won't hire someone to do it either.
This sounds like a great way to drive up extremely soft psych consults.
 

Salpingo

10+ Year Member
Dec 6, 2008
410
339
Status
Resident [Any Field]
At our institution we are going to target diabetes and depression. It means a couple of checks in the medical record to show that the doc looked at the feet and the patient filled out a two item depression screen. As a psychologist, I cringe at the implementation of these "interventions" without any type of research methodology being utilized. We have no idea if any of this will have any bearing on any real outcome measure and we are not comparing it to anything either. Of course, the ACA doesn't pay for an expert to design a quality care program so it defaults to someone with a business degree to implement this and it ends up being a checkbox in the CMR. As a psychologist, I have the skill set and also some experience with program development but I can't bill for it so there is no way that I can devote the time necessary for this and the hospital won't hire someone to do it either.
Is the goal to eventually use the IMPACT model?

http://care.diabetesjournals.org/content/29/2/265.short
http://impact-uw.org/tools/impact_manual.html
 
Mar 24, 2014
4,393
3,840
Rural Area Medical Facilty
Status
Psychologist
This sounds like a great way to drive up extremely soft psych consults.
They would be outpatient referrals and we could always use the business. Many people with mild depression can benefit from a session or two and some of those referrals can prevent more serious ER visits down the road. We also could end up with more no shows because by the time the appointment comes they feel better anyway.
 
Mar 24, 2014
4,393
3,840
Rural Area Medical Facilty
Status
Psychologist

heyjack70

Junior Member
10+ Year Member
7+ Year Member
Nov 24, 2005
745
247
Status
They would be outpatient referrals and we could always use the business. Many people with mild depression can benefit from a session or two and some of those referrals can prevent more serious ER visits down the road. We also could end up with more no shows because by the time the appointment comes they feel better anyway.
Is the screening done inpatient and then if positive for depression the patient is referred to outpatient therapy followup only?
 
Mar 24, 2014
4,393
3,840
Rural Area Medical Facilty
Status
Psychologist
Is the screening done inpatient and then if positive for depression the patient is referred to outpatient therapy followup only?
Most of the screenings would occur during outpatient clinic visits. When it is an inpatient who is positive for depression, then it can be an outpatient referral for psychotherapy and the hospitalist on duty might prescribe a psychotropic or consult with our PMHNP. We don't have a psychiatrist currently.
 

Lawgiver

Membership Revoked
Removed
Account on Hold
Jul 24, 2014
400
177
Status
Pre-Medical
An email went out today saying that for 2015, any physician who achieves 90th percentile or better on patient satisfaction will get a $10K bonus.

I really really wanted to "reply-all" that email with, "SWEET!!! Who wants some Adderall??!!" But I restrained myself.
haha!
 

Lawgiver

Membership Revoked
Removed
Account on Hold
Jul 24, 2014
400
177
Status
Pre-Medical
i think the best thing that could possibly happen to medical training would be to require everyone before graduation to work for 30 days in a healthcare call center as a Customer Service rep.

So many eyes would be opened.
 
OP
whopper

whopper

Former jolly good fellow
15+ Year Member
Feb 8, 2004
6,893
1,671
Visit site
Status
Attending Physician
At SLU I'm being told the patient satisfaction thing does affect psychiatry.
In yet another example of how the ACA isn't working intelligently, if our patients check their medical records via the Internet through EPIC's outpatient Internet options (designed for patients, it's not their complete record, kind of a patient-centered record), we get reimbursed more. Someone had the brilliant idea that if patients read through this stuff they'd feel more like a partner or master in their health.

One of those things that in theory seems good but....

Most of our patients don't have the Internet! They're poor, homeless, or paranoid that their records will be leaked or monitored!

We're already operating on a mechanism where we cannot fully be compliant with government recommendations!