Alexander Torres, DO
Comanche County Memorial Hospital, Lawton, OK

Patient satisfaction and its impact on healthcare and health outcomes dates back to the 1950s, where relationships between patients and healthcare providers were examined.¹ These relationships have become extremely complex as the healthcare industry has grown, and there is now legislation in the form of the Affordable Care Act (ACA) requiring that these relationships impact the business of healthcare in the form of reimbursement and consumerism. Operating as a service industry, healthcare has similarities to other firms whose goal is perfecting customer satisfaction and providing superior services or products. Fenton and associates² describe how high patient satisfaction is associated with high mortality, the opposite goal of the principles of healthcare. The purpose of this paper is to discuss how there has been a shift from the primary goal of medically treating patients to now treating them as consumers, and how patient satisfaction is changing the structure of healthcare.

Historical Background

In the early stages of examining patient satisfaction, the relationships between providers and patients were the main focus. It was found that patients experienced a lack of empathy, low levels of friendliness, and dissatisfaction from health services¹. Since the initial investigations, there have been numerous studies looking to determine what affects patient satisfaction, eventually leading to the current mentality that patients are “consumers of healthcare,” and therefore the healthcare industry should shift towards a model of consumerism. Since the 1950s, several socioeconomic factors have become a reality and have changed patient-centered care. Factors such as rising patient expectations, demand for greater transparency, and demand for immediate access to imaging and pharmacotherapy have impacted the direction of healthcare as an industry.³ Senić and Marinković¹ found that the last service encounter experienced by a patient is usually the encounter on which they will rate their overall experience.

In 2002, the Baldrige National Quality Program began awarding businesses in healthcare. The Baldrige National Quality Program works to “identify and recognize role-model businesses, establish criteria for evaluating improvement efforts, and disseminate and share best practices.⁴” These awards signify that a healthcare organization serves as a role model in its field based upon overall success. The award measures the success of patient care outcomes and processes, patient satisfaction, workforce satisfaction, and financial market performance, all of which lead to a successful organization.⁴

While patient satisfaction and patient-centered care have always been important, the passage of the Affordable Care Act by the federal government in 2010 set the stage for value-based purchasing; a system in which payments to healthcare organizations will be impacted by patient satisfaction scores.⁵ Patient satisfaction is measured in many ways, but the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are the most influential, as they make up 30% of the overall performance score for value-based purchasing. The paradigm suggests that improving patient-centered care and improved patient satisfaction will lead to better health outcomes.⁶ This has had significant impact on the structure of healthcare and has led to changes in priorities, goals, and objectives of many healthcare organizations.

Impact of Patient Satisfaction on Healthcare Structure

The implementation of the Affordable Care Act imposed major changes on the healthcare industry. As medical coverage is extended to patients under the ACA, the number of patients entering the healthcare system is expected to reach 32 million, leading to difficulties for the current system to accommodate these new healthcare consumers.⁷ As patients make their way through the complex medical system, they will have a multitude of opportunities to complete surveys that will impact various organizations’ HCAHPS scores. They will rate categories including nurse communication, physician communication, responsiveness, pain management, medication communication, cleanliness, discharge information, overall rating, and likelihood to recommend. These scores based on patient experience will ultimately be tied to the reimbursement of physicians and healthcare organizations under a pay-for-performance model.⁸

With value-based purchasing becoming so important, multiple studies have examined the effects that it would have on healthcare organizations in regard to financial impact and business models. Cliff⁵ found that by improving the patient experience, institutions can experience positive financial results. It was found that hospitals that rank amongst the best inpatient satisfaction are also some of the most profitable and financially sound institutions. As with most businesses, anything that positively influences finances and payments is a strong motivator for success. With patient satisfaction being so closely tied to reimbursement and financial rewards, healthcare organizations have been motivated to improve the patient experience.

Using HCAHPS categories as a basis for areas in which to improve, the healthcare industry has seen a shift in priorities, goals, and objectives. With managers being educated in business, healthcare has seen a trend towards providing tangible services and goods aimed at improving the patient experience while, at times, losing sight of a primary objective of medicine which is to positively impact a patient’s health and well-being. This can lead to increased healthcare costs that do not directly impact a patient’s health outcome.

Fenton et al.² describe the negative effects of achieving high patient satisfaction scores. The implications of linking physician reimbursement to patient satisfaction have led to a change in the practice of medicine. In attempts to satisfy patients, physicians have begun to order unnecessary testing (laboratory and imaging studies) simply to avoid negative impacts on reimbursement. This type of practice can quickly lead to an increase in overall healthcare costs, which is a major factor in the healthcare crisis currently being experienced in the United States. Greater patient satisfaction has been associated with increased utilization of healthcare resources and ultimately an increase in healthcare spending.⁵ Healthcare executives, in conjunction with physicians, must be wise to effectively and efficiently use resources to positively impact the patient experience while also containing costs.⁹ Physicians undergo extensive schooling and post-graduate training so that they will know what to investigate, how to investigate it, and when it should be investigated. By succumbing to patient requests for unnecessary testing, the physicians are compromising their ideals solely for the concern of decreased reimbursement as a result of dissatisfied patients.

Healthcare as a Service Industry

Service industries serve in the economy to provide services rather than tangible goods. These industries have become extremely focused on customer satisfaction to strengthen their places in competitive markets. Good customer service is extremely subjective, as each individual has their own idea of what is acceptable customer service. Service industries aim to provide individualized services, yet healthcare seems to be lagging by using generalizations from patient satisfaction surveys to provide for its customers.¹⁰ Healthcare is included in the service industry. Therefore, it is being treated as any other organization and is not seen as unique.

As the United States is seeing a shift in healthcare from treating patients to treating consumers, we are seeing an excessive amount of resources being used for advertising and marketing.¹¹ The market for healthcare providers is vast, therefore competition is increasing. When deciding on where to receive elective healthcare, patients tend to forget a hospital’s clinical outcomes and seem to focus on the “window dressings” of free parking, food quality, guest internet access, and other amenities. These amenities aim to earn repeat business and recommendations from current patients.

 

It is unfair to compare healthcare services, such as life-saving emergency care, surgery, chemotherapy, etc., to other services such as haircuts, online video streaming, and package delivery. Consumers of healthcare typically do not seek services because they are having a good day. Very few, if any, patients begin their day of receiving healthcare services in a good mood. They are preparing themselves for long waits, potential for receiving bad news, receiving medications that may make them sick, having to endure a needle-stick to have laboratory work performed, and other unpleasant situations. There are few services where consumers do not expect positive outcomes. Experiences like these make healthcare unique when it comes to its inclusion in the service industry of economics.

As consumerism is empowered in healthcare, the system is being placed under increasing pressure to conform to customer satisfaction practices, leading to shifts in the goals of providing patient care.¹² Healthcare providers are under significant stress with increasing demands from customers, payors, and government regulations; therefore, they are feeling that customer service is just one more thing added to their job requirements.¹³ Needham¹⁴ describes how patients, now considered consumers of healthcare, will begin to expect from healthcare what they expect from other service industries, such as value, convenience, and respect. Listening to customers for continuous feedback on their experiences is important for improving service quality, in both healthcare and traditional service industries.¹⁵ Healthcare leaders and management must have a strong foundation on which to improve patient satisfaction. This foundation should consist of empowering positive values and supporting change initiatives aimed at providing high-quality service.¹⁶

Patient Perceptions and Attitudes

Messina and associates¹⁷ describe how patients present to hospitals and clinics with their own agendas and expectations of what to expect with regarding service and care. This is true of consumers in many industries, and in some ways, healthcare is no different. Meeting service expectations and setting standards of behavior play a role in healthcare, but must be modified in certain situations.¹⁸

Many patients bring their own expectations to provider encounters. This includes demanding certain unnecessary testing, prescriptions, or other services. Patients tend to be more satisfied when physicians fulfill their expectations, regardless of whether the services are necessary.² This form of practice has led to inappropriate medication usage, increasing risk for adverse reactions to unnecessary interventions, and increasing healthcare expenditures all under the fear of decreased reimbursement. However, providing patient-centered visits where the provider has the time to discuss the patient’s concerns could both improve patient satisfaction while being judicious in the use of resources. This requires longer patient-physician encounters, which is proving more difficult to find in today’s healthcare system as the nation is currently experiencing a physician shortage. Satisfied patients are more likely to be compliant with their medical care plan, ultimately leading to improved outcomes and more efficient utilization of healthcare resources.¹⁹

With regards to the noncompliant patient, one can see the issues regarding reimbursement being tied with patient satisfaction. Fontenot⁶ describes how a physician trying to improve a patient’s health by empowering them to take a personal responsibility in their own care when that is not what they want to hear, will ultimately lead to a dissatisfied patient. These noncompliant patients’ attitudes toward their healthcare is poor, and yet it is the healthcare provider that is financially penalized.

Patients seeking healthcare services have varying backgrounds ranging from excellent overall health to extremely poor health with multiple chronic illnesses that require significant resources. The severity of patient illness impacts their perceptions of healthcare and the importance of various aspects. Otani et al²⁰ describe how patients with serious illnesses see patient-physician interactions and physician care as most important. As one might expect, patients that require frequent visits, procedures, and encounters with the healthcare system will have more opportunities to complete patient satisfaction surveys. As these patients are not regarded as being in good health, they are more likely to receive bad news, incur more healthcare debt, and require more resources all leading to a higher possibility of dissatisfaction with their experiences as well as the healthcare industry as a whole.

Satisfaction of Healthcare Employees

The healthcare industry would not be able to operate without cooperation between healthcare executives/administration, physicians, nurses, ancillary staff, and ultimately patients. The attitude of members of the healthcare team impacts sixty percent of patient experiences as well as patient perception of quality care and service.¹² Ensuring employee satisfaction will likely indirectly increase patient satisfaction.

Physicians play a significant role in the healthcare system, especially in the care of patients with poor overall health. With an aging population seen in the “Baby Boomer” generation, chronically ill patients are becoming the norm. It should come as no surprise that empowering physicians and focusing on their satisfaction should be a top priority for healthcare management. From the beginning of their studies, and often before, physicians aim to provide a satisfying experience for their patients. This sentiment is often missed when discussing patient satisfaction. Handel²¹ detailed how influencing physicians by honing in on their pride, professionalism, and natural problem-solving abilities can provide a positive impact on patient satisfaction.

Medical education has become increasingly focused on patient communication due to the impact it has on the patient experience, and ultimately, patient satisfaction. Ossoff and Thomason¹¹ found that physicians’ bedside manner, and the way in which they interact with patients, continues to be one of the most important factors in achieving high patient satisfaction scores. Improving bedside manner involves improving how physicians listen to a patient, deliver information or bad news, allow patients and families to participate in medical decision making, and the respect they show towards patients. These traits can be applied to nursing and ancillary staff as well. By influencing all members of the healthcare team to positively impact the patient experience, patient satisfaction is likely to improve.

Shannon²¹ describes the impact of physician well-being on the patient experience. More satisfied physicians tend to have higher patient satisfaction scores; however, physician dissatisfaction and “burnout” are on the rise nationwide. A recent survey of currently practicing physicians demonstrated that nearly half of those surveyed would not choose medicine again as a career. Another worrisome statistic is that nearly 30 percent of practicing physicians are considering leaving the profession within the next two years due to “burnout.” The factors leading to physician dissatisfaction are complex, but some of the most common issues faced by practicing physicians are issues with healthcare reform, some of which have been exacerbated by the passage of the Affordable Care Act. Physicians are concerned that they will face with reduced compensation and autonomy, along with worsening time constraints and increased pressures to complete administrative tasks all due to greater access to healthcare among patients that were previously not in the market for healthcare services.²¹ As value-based purchasing is becoming more prominent in the healthcare industry, it is imperative to focus on satisfied, engaged employees.

Discussion

As the information in this paper demonstrates, patient satisfaction is complex. There is no clear definition of patient satisfaction and the idea is highly subjective. Implementing a standardized approach is not likely to be effective as patients are looking for individualized care. Patient satisfaction is not simply focused on the patient experience, but it has now become closely linked to reimbursement for physicians and healthcare organizations. At present, much of healthcare organizations are managed by business-minded individuals, as opposed to medically-trained personnel, leading to healthcare being run as a traditional service industry. The ability to realize that the healthcare industry is unique in its role to provide services is of utmost importance. Tailoring to the unique aspects of healthcare will allow for overall satisfaction, from patients to employees.

The healthcare system must not lose sight of its primary objective, providing world-class patient care to improve patient health and well-being in a safe manner. Tailoring patient care and amenities to provide positive patient experiences should also be considered important, but should not overshadow the importance of improving health outcomes. Unfortunately, patients who provide high patient satisfaction scores experience higher mortality.

Limitations of the Research

The research included in this paper is not without limitations. Patient satisfaction is highly subjective and is easily influenced. There are many confounding variables when discussing patient satisfaction, therefore increasing the complexity of research studies. A majority of the research involves patient surveys and questionnaires, which reflects the patient’s personal views which are then applied to a generalized population. Human nature allows for patients to have a natural tendency to begin an experience with a predetermined expectation of how satisfying their encounter will be. Also, patient satisfaction surveys are conducted after each patient encounter, with a majority of visits being those patients with chronic medical conditions that are in poor health and often do not have good outcomes. The majority of the research studies referenced in this paper pertain to healthcare in the United States of America. It would be inappropriate to generalize these findings to healthcare around the world, as healthcare systems vary from country to country. Healthcare is changing on a daily basis; therefore, some data can quickly become outdated, increasing the importance of the need for ongoing research in patient satisfaction.

Future Research

Future research should be aimed at the comparison between healthcare systems and traditional service organizations. Also, as healthcare reform continues to be a major political and economic topic, the current healthcare system will likely change. As value-based purchasing is a relatively new concept, extensive research will be needed on what the true impact on patient satisfaction and overall health outcomes is going to be. With a person’s health being the true determinant of satisfaction with life, anything that can potentially have a positive impact on a person’s health should be investigated thoroughly.

Summary

In summary, patient satisfaction has overtaken the structure of the healthcare system. There has been a shift in the paradigm in healthcare from providing excellent medical care to now providing services and/or goods focused on improving the patient satisfaction. This model of healthcare has the potential to have a negative impact on the healthcare system as evidenced by decreased physician satisfaction and increased burnout. The nation is already facing a physician shortage, and the concern for the future is that taking the focus away from providing medical care in order to focus on making customers happy will lead to more physicians, nurses, and ancillary staff leaving the healthcare industry.

The role of patient satisfaction in the healthcare system is not straightforward. It is quite complex. With the implementation of the Affordable Care Act and value-based purchasing, the structure of healthcare is in for a change. We are seeing the financial impact of patient satisfaction on healthcare organizations, which is driving the business of medicine to change as financial stability is a strong motivator of business. With patients being considered as consumers, healthcare is seeing a trend towards increased competition, and therefore we are seeing increased expenses for marketing and advertising while healthcare organizations are seeking a competitive advantage. Healthcare reform is a quite popular and complicated topic that is under the control of governmental agencies, nearly all of which are headed by non-medical personnel. This is likely contributing to a shift in medicine towards a business model focused on improving patient satisfaction. As healthcare reform evolves, there are likely to be significant changes to the healthcare experience.

References

1. Senić V, Marinković V. Patient care, satisfaction and service quality in health care. International Journal of Consumer Studies. 2012;37(3):312-319. doi:10.1111/j.1470-6431.2012.01132.
2. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. 2012;172(5):405–411. doi:10.1001/archinternmed.2011.1662
3. Cliff B. The evolution of patient-centered care. Journal of Healthcare Management. 2012;57(2):86-88.
4. Griffith JR. Understanding high-reliability organizations: are Baldrige recipients models? Journal of Healthcare Management. 2015;60(1).
5. Cliff B. Excellence in patient satisfaction within a patient-centered culture. Journal of Healthcare Management. 2012;57(3):157-159.
6. Fontenot SF. Will patients’ happiness lead to better health? The ACA and reimbursements. Physician Leadership Journal. 2014;1(1):28-31.
7. McCaughey D, Erwin CO, DelliFraine JL. Improving capacity management in the emergency department: A review of the literature, 2000-2012. Journal of Healthcare Management. 2015;60(1):63-75.
8. Stanowski AC, Simpson K, White A. Pay for performance: are hospitals becoming more efficient in improving their patient experience? Journal of Healthcare Management. 2015;60(4):268-286.
9. McCaughey D, Stalley S, Williams E. Examining the effect of EVS spending on HCAHPS scores: A value optimization matrix for expense management. Journal of Healthcare Management. 2013;58(5):320-334.
10. Powers B, Navathe AS, Jain S. How to Deliver Patient-Centered Care: Learn from Service Industries. Harvard Business Review. April 2013. https://hbr.org/2013/04/how-to-deliver-patient-centere.html.
11. Ossoff RH, Thomason CD. The role of the physician in patient satisfaction. Journal of Health Care Compliance. 2012;14(1):57-72.
12. Lanser May E. Diagnosing the patient experience. Healthcare Executive. 2015;30(4):20-30.
13. Mayer T. Leadership for great customer service. Getting the “why” right before mastering the “how”. Healthcare Executive. 2010;25(3).
14. Needham BR. The truth about patient experience: what we can learn from other industries, and how three P’s can improve health outcomes, strengthen brands, and delight customers. Journal of Healthcare Management. 2012;57(4):255-263.
15. Kennedy DM, Caselli RJ, Berry LL. A roadmap for improving healthcare service quality. Journal of Healthcare Management. 2011;56(6):385-400.
16. Arbab Kash B, Spaulding A, Johnson CE, Gamm L. Success factors for strategic change initiatives: A qualitative study of healthcare administrators’ perspectives. Journal of Healthcare Management. 2014;59(1):65-81.
17. Messina DJ, Scotti DJ, Ganey R, Zipp GP. The relationship between patient satisfaction and inpatient admissions across teaching and nonteaching hospitals. Journal of Healthcare Management. 2009;54(3):177-190.
18. Scott G. The six elements of customer service: achieving a sustained, organization-wide commitment to excellence improves customer and employee satisfaction. Healthcare Executive. 2013;28(1):64-67.
19. Otani K, Ye S, Chumbler NR, Judy Z, Herrmann PA, Kurz RS. The impact of self-rated health status on patient satisfaction integration process. Journal of Healthcare Management. 2015;60(3):205-218.
20. Otani K, Waterman B, Dunagan WC. Patient satisfaction: how patient health conditions influence their satisfaction. Journal of Healthcare Management. 2012;57(4):276-292.
21. Handel DA, Delorio N, Yackel TR. The five P’S to influence physicians. Physician Leadership Journal. 2014;1(2):24-26
22. Shannon D. Physician well-being: a powerful way to improve the patient experience. Physician Executive. 2013;39(4):6-12.