Providing more low-value care doesn’t lead to higher patient experience ratings

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As hospitals, insurance companies and policymakers seek to improve healthcare quality and reduce rising medical costs, one important metric used to assess clinicians hinges on how patients feel about their healthcare experience. Many healthcare providers and policymakers fear that increased pressure to please patients – and ensure high satisfaction ratings as a result – could lead to overuse of low-value care that doesn’t provide any clinical benefit while unnecessarily ratcheting up medical bills.

But new research from the University of Chicago and Harvard Medical School may alleviate some of those concerns. A study published in JAMA Internal Medicine, found no relationship between favorable patient ratings and exposure to more low-value care.

At least one oft-cited study supports the concern that a focus on patient ratings will lead to more low-value care, finding patients with higher satisfaction ratings had higher odds of inpatient admission, higher healthcare and prescription drug costs, and higher mortality. This study implied that catering to patient satisfaction may lead to worse outcomes.

But those reporting the new findings this week said those past results emerged from flawed methodology, as they didn’t adjust for certain key factors, such as how sick the patient might be, which could be a confounding factor.

WHAT’S THE IMPACT?

For the new study, the team examined data from the federal Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, which uses patient-provided observations to measure things like communication with a physician, timeliness of scheduling an appointment and time spent in the waiting room. The team also analyzed Medicare claims to measure the amount of low-value care received by a physician’s patient panel.

Unlike past studies, the researchers’ approach relied on sampling independence and little overlap between the patients in the CAHPS and claims datasets. With this methodology, they were able to eliminate patient-level, unconnected factors that could influence the results, and gain what they considered a more objective look at the relationship between patient satisfaction and low-value care exposure.

They concluded that the concerns about low-value care are overblown. While there was indeed a wide range of low-value care across physician patient panels, there was no direct link between low-value care exposure and favorable patient ratings. In other words, physicians whose patients get more low-value care aren’t getting higher ratings.

There are several reasons why that might be the case, such as physicians informing patients why a requested test or procedure is unnecessary, or because most low-value care is due to provider practice patterns rather than patient demand.

Understanding how patient experiences and ratings are impacted by the types of care they receive has important implications for future policies and funding models geared at reducing wasteful healthcare spending while improving the overall quality of care.

THE LARGER TREND

Despite the findings, low-value healthcare continues to be a problem. An estimated 10{f08ff3a0ad7db12f5b424ba38f473ff67b97b420df338baa81683bbacd458fca} to 20{f08ff3a0ad7db12f5b424ba38f473ff67b97b420df338baa81683bbacd458fca} of healthcare spending consists of low-value care, defined as patient services that offer no net clinical benefit in specific scenarios. These items include many common treatments, such as the prescribing of antibiotics for uncomplicated acute upper respiratory infections.

Spending on low-value healthcare among fee-for-service Medicare recipients dropped only marginally from 2014 to 2018, despite both a national campaign to better educate clinicians and increasing use of payment revisions that discourage wasteful care, according to a new RAND Corporation study from February.

Three items accounted for two-thirds of the low-value care. One of these is an increase in prescribing opioids for acute back pain, despite a growing national awareness of the harms caused by the drugs and the role of this type of prescribing in fueling the nation’s opioid crisis.

The proportion of study participants receiving any of 32 low-value services decreased from 36.3{f08ff3a0ad7db12f5b424ba38f473ff67b97b420df338baa81683bbacd458fca} in 2014 to 33.6{f08ff3a0ad7db12f5b424ba38f473ff67b97b420df338baa81683bbacd458fca} in 2018. Annual spending per 1,000 individuals on low-value care also decreased from $52,766 to $46,922, from 2014 to 2018.

In a 2017 study that honed in on the Commonwealth of Virginia, researchers analyzed 5.4 million of the 44 healthcare services included in the study received by Virginia beneficiaries and found that 1.7 million of them were low-value – which cost more than $586 million. That is equal to 2.1{f08ff3a0ad7db12f5b424ba38f473ff67b97b420df338baa81683bbacd458fca} of Virginia’s healthcare costs, which totaled $28 billion that year.

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