The modern experience of care: patient satisfaction as a quality metric after the Affordable Care Act
Moriarty, John Michael
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The Hospital Value-Based Purchasing Program (HVBP), created by Section 3001 of the Patient Protection and Affordable Care Act passed in 2010, enacted a major industry shift in Medicare towards "pay for performance," or paying for high marks on a variety quality metrics rather than the traditional reliance on volume of care delivered. This study examines one of these quality metrics in particular: patient satisfaction. The trajectory of this paper begins with an overview of the current focus on patient satisfaction as a modern quality metric in American healthcare, contextualizes this emphasis on satisfaction within the intellectual movement of "patient-centered care," and moves on to a review of the relevant scholarship that attempts to explain the numerous determinants of patient satisfaction scores (with special attention to the inpatient hospital setting), as well as the robust academic debate over whether satisfaction is even an appropriate quality metric at all relative to clinical outcomes in care. The second half of my discourse moves on to more practical applications - first I break down the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and the impact of its methodology on providers, then the Medicare HVBP program itself and its various directions towards the value-based care model. I conclude with a quantitative analysis of trends in patient satisfaction over time between 1) HVBP-participating providers (as of FY2014) and 2) those providers who have not opted in (including those ineligible to do so). My comparison aims to study the strength of the HVBP incentives to improve patient satisfaction in those subject to the financial incentive relative to those who are not. Additionally, I preface this analysis whether patient satisfaction scores are associated with either clinical process of care scores or outcome scores in the HVBP program. My research questions aim to shed light on the academic debate between patient satisfaction and more traditional clinical outcomes - are they related in the context of FY2014 HVBP? Are the new incentives to improve patient satisfaction actually doing so in a meaningful way among providers newly accountable to these incentives? Finally, in a market defined by zero-sum resources, is there evidence that a financial incentives around patient satisfaction are channeling resources and by extension improvement away from clinical outcome performance? I believe this last question is the true concern of patient satisfaction skeptics, and hope to address it with applicable data. By providing a thorough qualitative grounding in the topic followed by current quantitative analysis, my goal is to create an informed perspective on the use of patient satisfaction as a quality metric in U.S. healthcare, which can be applied meaningfully from policy, provider, and consumer vantage points. With patient satisfaction becoming increasingly more internalized in the value-based care model, these analyses of the initial results in HVBP potentially serve as predictive insight into provider behavior in this area moving forward.