So the healthcare financial situation is dire and, frankly, depressing. But do you know what can make a meaningful difference in reversing this situation for health systems? Take a guess.
That’s right. Compassion. How? Because it actually drives revenue and reduces costs.
Let’s first take a look at revenue. Compassion not only improves clinical quality, motivates better patient self-care, and confers all the other benefits discussed so far, but it actually drives revenue in health care organizations that excel in compassionate care.
It won’t make the total revenue “pie” for the industry any larger. Rather, it will increase the piece of the pie for organizations that consistently use it. And why would that be?
Patient Experience Drives Business
The term “patient experience” (also sometimes called “patient satisfaction”) encompasses the range of interactions that patients have with the health care system, as rated by the patient. It includes several aspects of health care delivery that patients value highly when they seek and receive care, such as good communication with health care providers.270 In recent decades, hospitals and other types of health care organizations have conducted surveys to assess this. Quite frankly, the surveys have not been that popular among those that deliver care.
Physicians—and staff, too—have sometimes balked at being rated on things like how responsive or timely they were. When patients ding them for poor performance, they can sometimes feel resentful because they don’t always see those things as under their control or related to the quality of the clinical care they have provided.
For example, a surgeon doesn’t just want to be judged on how well they explained instructions at the time of a patient’s discharge from the hospital; the surgeon would rather be judged on the complex factors that were carefully navigated in the operating room to save the patient’s life…while the person filing out the survey was unconscious. Some physicians and nurses also worry that patients will rate them poorly if they refuse unreasonable requests (such as pain medications or antibiotics when they’re not clinically warranted).
Dr. Zubin Damania, also known as “ZDoggMD” within the medical community for his viral comedy sketches and parodies, captures this conflict adeptly in one of his videos.271 In the video, his character, Doc Vader, who often models poor behavior, suggests that the survey should only have one question: “Did you die?” Because if the patient is still alive, the doctor should receive a perfect score on the survey.272 (Along the same lines, you may have seen a nurse, during non-work hours, wearing a t-shirt that proudly proclaims, “I’m a nurse. My job is to save your butt, not kiss it.”)
But think about this a moment. Isn’t it sort of crazy that medicine hasn’t always taken an interest in asking patients what they think about the care we provide? In most other aspects of our lives, we expect to be asked for customer service feedback on purchases we make and services we use. But not when it comes to health care, arguably one of the most critical services we will ever purchase?
ZDoggMD’s Doc Vader suggests that if the patient isn’t happy, he can just go somewhere else.272 And that, in fact, is exactly what patients do.
So while critical feedback from patient surveys may upset some health care providers, and may not be a true proxy of quality, it is insight into how patients feel about the care that is provided. No matter how physicians and nurses feel about it, patients will make decisions based on how they are treated, and the payers—including the federal government—want to know that the care they are paying for includes valuable aspects of customer service.
In any case, back in 2006, the federal government rolled out a mandated and standardized patient experience survey for hospitals, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Its 32 questions ask patients about everything from how well nurses and doctors communicated, to how clean the room was, and how well staff explained medications and discharge instructions.
Since then, the HCAHPS survey has also been adapted so patients can rate a whole range of health care organizations—everything from outpatient office practices and emergency departments to dialysis centers and hospice care. The results on those surveys are an important determinant of how well a health care organization is reimbursed for the care they provide.
Hospitals that are rated highly on their patient experience scores are also higher performing hospitals financially.
But let’s stick with the hospital example specifically in our examination of patient experience here. It turns out that hospitals that are rated highly on their patient experience scores are also higher performing hospitals financially. That’s probably not surprising when you lay it out. It’s kind of a “duh” moment, isn’t it?
Happy customers drive business in all industries, and health care is no different. That’s why we get so many requests to rate the businesses we use—so that other potential customers can read about how happy we were (or not) with the service.
So yes, happy customers drive business and revenue in health care. In fact, a Deloitte study showed that hospitals rated by patients as “excellent” on the survey earned (average net patient revenue, per adjusted patient day) 127 percent of what hospitals that were rated as “low” earned.273
The costs were also higher for high-performing hospitals, but this was outpaced by the revenue increase. Another way of explaining the higher associated costs might be that hospitals whose patients rate them highly also tend to have more revenue to invest back into the patient experience.
In a similar vein, hospitals with higher reported patient experience are also more profitable; their revenue exceeds their costs by a higher amount. Those that were rated “excellent” outperformed low performers with a margin of 4.7 percent, on average, compared to just 1.8 percent.273
To people who don’t study health care financials for a living, that 2.9 percent difference might not sound like much money. But for many U.S. hospitals, it could be the difference between seeing patients or shuttering the place.
So how does compassion for patients factor in? One Virginia Commonwealth University study of 269 hospitals found a direct link to compassion with respect to profitability: It was all about the employees.274 Researchers found that hospitals with a “compassion culture”—they rewarded employees who practiced compassion and even supported struggling employees with pastoral care—were more likely to be rated higher by patients, and patients were more likely to recommend the hospital to others. These compassion practices translated directly to top ratings by patients on the federal HCAHPS survey mentioned above.
Compassion creates “patient-centeredness.”
One of the reasons why a compassion culture translates into delivering top patient ratings is because compassion creates “patient-centeredness.”274 When an organization encourages its employees to detect and respond to suffering, they put the patient at the very center of everyone’s care, and patients can sense it. Rather than feeling that they are just one more body being shuttled into and out of the system, they feel “seen as a person” and valued.
Hospitals that recognize the value of this approach are intentional in creating a workplace culture of compassion. They understand that health care workers experience suffering, too, and actively work to address and heal those effects. For instance, Cleveland Clinic has employed a practice called “Code Lavender.”275 They deploy a team to support employees who need emotional support after a tragic event occurs (like an unexpected patient death) or a series of especially stressful events in the workplace.276 By demonstrating compassion for employees, they prime them to care for patients with the same sensitivity because they are more engaged and invested in the organization.274
This all has important implications for an organization’s financial health because a positive patient experience gets rewarded by payments from the federal government. One reason that hospitals delivering a better patient experience are more profitable is because CMS actually reimburses hospitals t
hat perform better on the survey at a higher rate through its Medicare value-based purchasing (VBP) structure.277
But the Deloitte survey also suggests that this tendency to perform better financially goes deeper than just the bump in reimbursement or increase in volume. In fact, when the researchers looked at the correlation between hospital financial performance and a variety of factors, they found that Medicare VBP incentives accounted for just seven percent of the association between patient experience and strong financial performance.273
Hospitals and health systems can increase their margin, the difference between their revenue and expenses, if they are able to reduce costs. In a study that analyzed cost data for three thousand U.S. hospitals, researchers found that better patient experience in the hospital was associated with lower health care spending per episode of care.278 In fact, there was a 5.6 percent difference in spending between the hospitals with the lowest and highest patient experience ratings. The research adjusted the analysis for complexity of care and socioeconomic status of those hospital patient populations, so we can be confident in these results.
But let’s consider the results from the Deloitte study again for a moment. Do you know what they found mattered most, when they considered all the factors that could account for stronger financial performance based on patient experience survey ratings? It was the nurse-patient relationship.273 Communication with nurses is one of the things measured on the HCAHPS survey instrument. That matters to patients. Again, the results are not surprising, right?
One of the key ingredients to communicating effectively with patients is, of course, the ability to genuinely express compassion. Health care providers are frequently surprised that when patients are surveyed, time and again, they say that they value their doctors’ interpersonal skills even more than any of the items on their résumé.
Patients Want Compassionate Care
In one Harris Poll, published in The Wall Street Journal, that asked people what they believed were the most important qualities in a physician, 85 percent of people said “treating me with dignity and respect,” 84 percent said “listening carefully and being easy to talk to,” and 81 percent said “truly caring about me.” In comparison, the proportion of patients who said that the physician being trained at one of the best medical schools was important was just 27 percent.279 So three times the number of patients value human connection and caring from their physician more than the prestige of the institution where the physician was trained.
Three times the number of patients value human connection and caring from their physician more than the prestige of the institution where the physician was trained.
Just a little over half—58 percent—agreed that having “a lot of experience treating patients with your medical condition” was extremely important!279
Moreover, 14 percent of respondents who said they had changed doctors in the past five years said that was because the doctor “didn’t listen carefully.”279
That’s because what people really want from health care goes to the very core of the doctor-patient relationship. Compassion is at the very top of that list.
Consider the results from one “man on the street” study. Researchers from George Washington University asked random adults—people in coffee shops, senior centers, community centers, and transportation stops—what they most wanted from health care and also what they thought could be done to most improve health care.280 They asked them to recall a positive and negative experience with health care and to explain the factors that made it such.
Just like in The Wall Street Journal report, the top three suggestions for improving health care were: more doctors who listen (85 percent), doctors who are caring and compassionate (71 percent), and doctors who explain well (69 percent). The doctor-patient relationship was at the very heart of their answers.
Conversely, only 22 percent of people indicated “ensuring doctors disclose financial conflicts of interest.” And only four percent said, “having a doctor of the same language” is important. Not just that, it’s also 17 to 20 times more important to patients in this study that their doctor listens and is compassionate than that their doctor even speaks their native language.
People’s perceptions of health care are all about relationships.
Patients clearly value a doctor who listens, who is caring and compassionate, and who explains well. Note that when people are asked about their health care experiences, they speak about the interaction between themselves and their doctors. People’s perceptions of health care are all about relationships.
Just listen to some of the things that patients in this study shared about their experiences below.280 Take a moment to notice the difference between negative and positive experiences:
On having a doctor who listens:
“I have a problem with my M.D. He sends me off to lots of specialists and to get tests before he even listens to everything I have to say. It seems like he doesn’t even listen to what my whole problem is. He could maybe solve it himself.”
“My doctor listens to everything about me—how my medical problem affects me as a person, daily life, emotions, my family, etc.”
On having a doctor who is caring and compassionate:
“I really didn’t like this one doctor. He didn’t even look at my face. He kept walking. I felt discriminated against. Maybe he didn’t talk to me because my English isn’t so fluent and I’m old. He didn’t care.”
“I want doctors to have compassion and show my loved one that they care about them as a human being, not just another case to solve.”
On having a doctor who explains well:
“I don’t like my own doctor. I go in for a sore throat and she tells me I’m fine. She trivialized my complaints. She doesn’t share her thought process.”
“I love my doctor…She translates things so that a normal person like me and you can understand them.”
The results of online consumer research studies corroborate the results of this “man on the street” study. When the ratings companies Healthgrades and Medical Group Management Association partnered to study seven million online patient reviews of their health care providers, they found that more than half of patients wanted compassion and bedside manner from their doctors.281
That’s a big deal since one online marketing company’s survey showed that 84 percent of patients said they consult online reviews before selecting a provider.281 Several online review sites, such as Healthgrades, are now partnering with health systems to allow patients to schedule appointments with a physician—right from the review website. Think about it like this: It’s just like how you can call a retail store or restaurant from Yelp or Google on a smartphone without having to go to the official website for the business you wish to call.
The report even pointed out that “…health care consumers view health care first and foremost as a personal interaction and not just a medical transaction.” Actually 52 percent of respondents’ online comments mention words like “compassion,” “comfort,” “patience,” “personality” or “bedside manner.”281
Health care consumers view health care first and foremost as a personal interaction and not just a medical transaction.
Online reviews from patients consistently focus on—in both negative and positive terms—how their doctor made them feel, if the doctor listened, and if the doctor and the staff were friendly. Perhaps most importantly, the study authors noted, “this new analysis reflects a patient population that doesn’t just want to see a doctor; they want to be seen.”281
Compassion is a vital driver of patient experience. In one study from Harvard Medical School that examined patient satisfaction with providers, researchers asked 112 new patients to complete a survey that examined everything from outcomes and functional recovery to wait times and visit duration.282
There was no difference between the satisfied and the dissatisfied patients when it came to waiting time in the office or lag time from calling to getting an appointme
nt date. However, after controlling for potential cofounding effects, they found that it was compassion that accounted for fully 65 percent of the variation in how patients rated their satisfaction with their health care provider.282
Compassion accounted for 65 percent of the variation in how patients rated their satisfaction with their health care provider.
Numerous other studies have linked compassion to patient experience. In one of these studies, researchers surveyed primary care patients and found that patients who said they were more satisfied on the survey were highly likely to rate their physicians as more compassionate, and those patients were also very likely to recommend that physician to family and friends.283
Another way to find out what qualities patients want in a physician is to ask them which physicians they like best and then watch those patients’ interactions with the well-liked physicians. What if researchers could review these interactions—just like professional football coaches review game day tapes—to figure out how to get better? What would that show?
That’s just what they did in a University of New Mexico study in the late 1970s: Researchers observed the behavior of internal medicine resident physicians with their patients through a one-way mirror. Afterwards, patients were asked to rate their satisfaction with their physician on an eight-item survey.284
Compassionomics Page 24