Patient satisfaction surveys constrain the practice of medicine

Press Gainey is not going to like this one.

I have a lot of family and friends who work in hospitals. On occasion, they will complain about a poor patient satisfaction score they received. There are several sides to the story, of course, but from their perspective the reason for the low satisfaction score received is because of some intervention, or lack of intervention, they are required to do (or not do) at the doctor’s orders. In the field of medicine, and other fields where professional expertise is what the customer needs and is seeking out, customer satisfaction surveys may be working against the best interest of the patient.

“Doctors feel pressured by what patients may say about them afterward. The fear of bad patient-satisfaction scores, or negative reviews on online sites, may be creating a “Yelp effect” that drives doctors to provide care that patients don’t actually need.”1

Antibiotics are often the over-prescribed medication, but in the Emergency Room and other areas of medicine, like dental visits, where pain management is common, opioids are often the sought after medication by patients that drive their response to a patient satisfaction survey. Doctors and dentists are then in an uncomfortable position of not meeting their customer’s needs, but for the customer’s own good. The patient can then just shop for a doctor or dentist that will prescribe the sought after medication. Drug seeking patients

“Some healthcare providers now sadly believe2 that ER patients with honest pain complaints are the minority.”3

Part of the problem is actually caused by government-mandated programs.

In order for a health care provider or hospital to be certified to receive payment from government-funded programs like Medicare and Medicaid, the provider must collect patient experience data, i.e. patient satisfaction, through the Consumer Assessment of Healthcare Providers & Systems (CAHPS) program. Physicians, hospitals and other health care providers must have sufficient scores from the CAHPS surveys in order to remain in good standing within the program they participate.  They can incur fines, reductions in reimbursement, or be removed from the program if CAHPS scores are too low. There is a real financial incentive for doctors, hospitals and other medical service providers to do the things that patient expects to insure a sufficiently high rating on CAHPS, contributing to over prescription of antibiotics and opioids.  and In the U.S. we have been indoctrinated with They may be so tightly scheduled that they get decision fatigue; physicians write more prescriptions at the end of their workdays than they do at the start.

As The Hippocratic Oath infers, “First, do no harm,” ending the CAHPS program may be the first step in giving back to physicians the ability to practice their art without undue retribution.

Government funding of health care services has numerous unintended consequences, and CAHPS is just one of them. Ending CAHPS will not solve the over-prescription epidemic in this country, but it is a solid, small first step.

The myopic American Dental Association

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

― Upton Sinclair, I, Candidate for Governor: And How I Got Licked

The American Dental Association’s (ADA) Health Policy Institute recently published a research paper4 addressing the need for a Loss Ratio for dental plans. In crafting their argument, the authors of the paper reveal their fundamental ignorance of how the dental insurance market works.

Using data made available by the State of California and through an exercise of tortured logic, the paper contends that because the dental insurance market is moderately concentrated, one solution to alleviating the effects of this moderate concentration would be to require all dental insurance companies to reach a minimum loss ratio for its dental policies sold in the state of California.

The study identifies that the dental insurance market is moderately concentrated based on the Herfindahl-Hirschman Index5. The major reason for this finding is the dominance of one company, Delta Dental of California. The authors identify two possible implications of a moderately concentrated market: higher premiums for consumers and lower reimbursement rates for providers.

Using the California data, they recognize that the dental premiums available to consumers has actually declined. over the two years of data they analyzed. Including data from a third year (made available after the paper was published) the trend of declining dental insurance rates is confirmed. So higher premiums is not the cause of their concern.

The American Dental Association’s concern is not the well-being of dental patients, but the well-being of dentists. Their primary goal is to protect the income of their members, dentists. With that in mind, they find some evidence that reimbursement rates for dental procedures paid by insurance companies may be declining modestly. The source of this data is from a lawsuit with Delta Dental of California. Reimbursement rates may be part of the problem.

Having been thwarted on their premium argument, and having inconclusive evidence on their reimbursement rate argument, they substitute medical loss ratio as a proxy. The medical loss ratio is simply:

Total claims paid


Total premium collected less taxes paid

The difference between Total Claims and Total Premium less taxes is administrative costs and profit.

In order to achieve the ADA’s goal of a medical loss ratio for dental insurance of 80% or 85%, there would have to be a decrease in administration costs, a decrease in profit, and/or an increase in provider payments.

Decreasing administration costs is most easily achieved through economies of scale. The bigger a company is and the more people it has to manage, the administrative cost per person will go down. So the large companies will have the advantage. Remember, Delta Dental of California is the largest.

Decreasing profitability can only be achieved through regulation. In economic parlance this is called price controls. Investors generally invest money in a business that has the possibility of making a return on their investment. Pension funds, like the California Public Employees’ Retirement System have a target return within their fund of 7%. So it stands to reason that investors in dental insurance companies would seek out a similar rate of return.

Right now, profitability for all dental insurance companies in California is around 6%. Limiting profitability beyond this level will only encourage business that are not achieving a sufficient return to leave the market. Fewer companies in the market will have the effect of causing additional concentration in the market, the cause of lower reimbursement rates according to the study authors.

Increasing provider payments, all things being equal, will require higher premiums. Clearly higher premiums is not good for the consumer. Higher premiums is also not good for the dentists. Higher costs means fewer people will spend money on dental insurance. Since most people rely on dental insurance to pay for their dental services, fewer people will seek out dental care. Lower demand without a concomitant reduction in supply will force dentists to charge lower prices, but since the prices are essentially fixed by the State, supply will have to shrink. Some dentists will either move out of state or just go do something else. The result is either lower income for dentists because of reduced demand, fewer dentists practicing or some mixture of both.

The Health Policy Institute, through its recommendations is more likely to harm the very constituency they aim to help, the dentists.

What I learned watching 60 Minutes

Last night, I was lying in bed reading a book while my wife watched a recorded episode of 60 Minutes. The theme of the episode was about Americans making a difference. A segment came on about the Health Wagon, a mobile clinic that travels the back roads of Virginia in Appalachia country providing health care services to those too poor to have health insurance, but too rich to receive Medicaid.

I learned two very important things by watching that segment, both of which I already knew, but hadn’t really grokked (The book I was reading was Stranger in a Strange Land by Robert Heinlein, hence the use of the word grokked).

Lesson #1: Individual Health Requires Individual Responsibility

Every one of the people featured as Health Wagon patients had conditions or diseases linked directly to poor lifestyle. Diabetes, emphysema, heart disease. Every one of these conditions can be prevented and even eliminated by making good lifestyle decisions. Decisions as simple as stop smoking, don’t eat nutritionally vacuous food, walk. To be fair, the folks featured in the story probably don’t have the education to know these things, as their lifestyle choices are likely a result of bad information passed down over a couple of generations. The agricultural policies of the federal government haven’t helped either, promoting crops that maximize calories rather than nutrition. The key to changing the health landscape of this country has got to start with what goes in the body, not how to repair the damage.

Lesson #2: The Jobs in the Coal Mining Industry are not Coming Back

At one point, Scott Pelley made a comment about how coal is mined, “In coal these days, they just take off the top of a mountain, and you don’t need many men for that.” The people who rely on coal for their livelihood are in a tough position. The opportunities they grew up with are quickly disappearing. The only hope they have is to learn how to do something else. Most likely that would require them to leave the only home they’ve known and go to where the educational and economic opportunities exist. That’s hard. It’s hard financially, it’s hard emotionally, it can be hard physically.

Part of solving the health care problem might be in solving the economic opportunities problem. Both problems require education and a bit of hard work.