Compassionomics

  The findings: The patients who said their physicians were especially courteous and better communicators were more satisfied. Researchers also found that when physicians were perceived as compassionate, patients were more likely to rate that physician as enjoying his or her work. On a side note, they found no correlation between how a physician looked and patient satisfaction—even among physicians that researchers identified as dressing “counter culture.”284

  For a study done in the 1970s, this means that even if physicians dressed with wide bell bottoms and flowered, wide lapel shirts/blouses, it didn’t matter to patients of any age…as long as the doctor was compassionate. (This is perhaps notable because in health care organizations there is likely more time spent in new employee orientations on the dress code policy then there is on treating patients with compassion!)

  Patients Would Pay More for Compassion

  In 2013, Dignity Health, one of the top five largest health systems in the U.S., released findings from a survey that showed when choosing a health care provider, 87 percent of Americans feel kindness is more important than any other consideration…even wait time, how far the provider is from their home, or cost.20 This nationwide email and online survey study included responses from 1,400 U.S. adults. We can have confidence in the reliability and accuracy of these findings because the survey included a rigorous methodology (including quotas for demographics of respondent) to ensure a nationally representative sample.

  64 percent of people in the survey said they had experienced unkindness in a health care setting where caregivers failed to connect personally, were rude, or didn’t listen.

  Fully 64 percent of people in the survey said they had experienced unkindness in a health care setting where caregivers failed to connect personally, were rude, or didn’t listen.20 Caring is the most important thing to patients and yet, the majority of people have not consistently received it during their interactions with physicians, nurses, and staff.

  Nearly three-quarters of patients in the survey said they would pay more for a physician who placed an emphasis on kindness. Nine out of ten said they would feel like switching health care providers if they were unkind.20

  This idea that patients would actually pay for compassion is also supported by a survey that specifically studied the role of compassion in medicine.285 The research shows that patients would pay more for compassionate care.

  Eighty-five percent of patients said compassion was very important to them for their satisfaction with health care providers and that they would choose compassion over pricing when choosing a doctor. For the purpose of comparison, just 48 percent of patients said wait time was very important, and only 31 percent said cost was very important.285

  Patients Perceive Compassionate Physicians to Be More Competent

  Patients may be willing to pay more for compassion, and they may rate compassion as more important than other factors, but they still want to know that their physician is skilled. Does compassion play a role in how patients view the competency of a provider?

  The data say yes.

  You’ve already seen some of this data back in Chapter 6, in our discussion of the link between compassion and clinical competence. For example, you saw a study of medical students that found both verbal and non-verbal expressions of compassion contributed to the perception of clinical competence by the supervising physician evaluators as well as the patients.250

  In that study, researchers asked independent observers to rate the compassion of students participating in the study. Then, they asked independent observers to judge their clinical competence.

  When they compared these ratings, they found that more compassionate students were also perceived to be more clinically skilled. It’s important to note that the student ratings of their own compassion were not associated with the judgments of clinical competence by the physician evaluators or the independent observer ratings of compassion.

  And yet, the more compassionate group outperformed the less compassionate group in ratings of clinical competence by 15 percent.250 Other studies have confirmed this finding that patients treated with compassionate care are more likely to believe their health care provider knows what they are doing.252, 284

  Multiple studies show compassion communicates competence.

  Why is this important in our discussion of money? One way to beat a rival for market share and increase an organization’s revenue in health care is to grow its reputation as more competent than its competitors. Compassion might just be the tool to use.

  As you’ve seen with other studies on expressions of compassion, it’s not just what providers say, but their non-verbal actions that matter as well. In Chapter 6, for example, you learned about a collaborative Harvard-Yale study that tested this relationship between physicians’ compassionate non-verbal behavior and patients’ perception of their clinical competence.252 It identified a positive correlation.

  To put it bluntly, you are going to have trouble building your practice and generating revenue if your patients do not think you are a competent doctor. How can you make them understand you are more competent? Treat them with more compassion. This is not our opinion; it’s what the data show.

  Medical Errors Erode Revenue

  One of the things threatening the already razor-thin operating margins of many health care organizations is medical errors. Aside from the obvious damage to reputation that can occur from medical errors that become known to the marketplace, medical errors also have direct financial consequences to health systems and providers.

  Increased errors will decrease value-based purchasing and pay-for-performance revenue.

  That’s a problem: These funding sources are an increasing portion of reimbursement to hospitals and physicians, not only by Medicare, but also by many commercial insurance companies.

  Earlier, you saw how the case for compassion falls into two categories: a lack of compassion causes problems and the presence of compassion confers benefits. So let’s look next at both cases with respect to medical errors and clinical competence.

  Provider burnout, as you may recall, is characterized as emotional exhaustion and the tendency to depersonalize patients (having no personal connection). Burnout has contributed in a big way to the compassion crisis in health care today, so you’ll learn more about how to specifically counteract this unfortunate phenomenon soon (Chapter 10).

  But for now, take a moment to think about the earlier link we established between depersonalization/emotional exhaustion and a greater incidence of medical errors (Chapter 6). There’s a strong correlation between the two. Unfortunately, those errors have direct and widespread financial consequences that extend far beyond the walls of the organizations where those providers practice. They adversely affect the whole U.S. health care system.

  According to a 2010 study sponsored by the Society for Actuaries, medical errors cost the U.S. $19.5 billion dollars annually, with $17 billion due to avoidable medical costs attributable to the errors, $1.4 billion due to increased mortality rates, and $1.1 billion due to lost productivity from missed work.286, 287 But according to recent research, that may actually be a gross underestimate.

  In a study in the Journal of Health Care Finance, researchers consider more recent data that suggest a much higher rate of medical errors. They are also more granular in their calculations, such as accounting for the lost productivity of those that lose their life due to medical errors for up to ten years, rather than just one year (depending on life expectancy)—something that was not done in the earlier study. The new annual U.S. estimate: between $735 billion and $980 billion.288

  As you’ve learned, compassionate care means more meticulous care for better clinical outcomes. If an increase in compassionate care could reduce medical errors in such a way that recaptures even a small fraction of that lost revenue, it would be an enormous windfall indeed.

  If compassion moves the needle just a little bit on medical errors, the economic impact could be substantial.
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br />   And, as you’ll soon see, there are effective ways to counteract burnout to achieve this goal. The take-home point here is that if compassion moves the needle just a little bit, the economic impact could be substantial because of the massive costs that are involved.

  Compassionate Physicians Refer Less and Order Fewer Tests

  One of the reasons that compassion can make such a meaningful difference to cost cutting is because connecting with patients is associated with lower medical expenditures. That’s because it’s part of patient-centered care. Compassion is “other-focused.”

  It’s not about the needs of the physician or the nurse or the organization; it’s all about the needs of the patient. Patient-centered care is not some vague concept. Studies have determined that the impact of patient-centeredness on quality outcomes can be reliably measured.289

  So why do compassionate physicians order fewer tests? Let’s start with some myth-busting. There is a misperception that the best doctors order lots of tests and refer patients to every possible specialist. The myth goes like this: “My doctor is the best. He orders every test under the sun.”

  But it’s just not true that this is what patients want. A few pages back you read that when patients are asked what they want from doctors, they ask for more caring and personal connection, not necessarily more tests.

  But let’s see what happens in practice.

  In one study from University of California Davis that considered the practice styles of nearly a thousand primary care physicians and the outcomes of their patients, researchers concluded that patients who felt their primary care doctors practiced patient-centered care were less likely to utilize excessive health care services.290 They also had lower medical bill charges. Median charges per patient were 51% lower with patient-centered care.

  One big reason why was fewer referrals to specialists. That makes good sense, right? If your doctor takes time to listen to your concerns and shows compassion for your suffering, you are more likely to trust the doctor’s recommendations. Conversely, if your physician seems distracted, doesn’t make eye contact, or generally seems burned out, your confidence in those recommendations might wane. You might be thinking, “Better to get another opinion,” as you request a referral to see a specialist.

  Or maybe you don’t actually verbally ask for a referral, but you transmit your anxiety and uncertainty about what your physician is recommending with lots of non-verbal cues. The physician gets the sense through your fidgeting and hand-wringing that you’re not on board with the plan.

  So, to pacify you, extra tests or referrals are ordered. Or if the physician does not really care enough to spend time talking with you, he might find it easier to just order the extra tests or refer you to someone else.

  Patients who do not feel a strong personal connection with their physician receive more referrals to specialists and undergo more diagnostic tests.

  And that’s exactly what researchers in this study concluded. When these primary care patients didn’t feel a strong personal connection, they ended up with higher referrals to specialists and more diagnostic tests. They measured specific communication behaviors like eliciting understanding, validating the patient’s perspective, and coming to a mutually shared understanding of the problem.290

  Patient-centered physicians in this study also made an effort to understand what the study authors called the “psychosocial” context of the patients: the combined factors that come together to “know them as a person,” as we’ve discussed. They wanted to understand the things in patients’ lives that might derail their recovery or motivate them to work hard to regain their health.290

  Recall our earlier discussion from Chapter 5—the chapter about patient self-care—on patient “activation.” That was the concept where a health care provider successfully engages patients in independently managing their own care when they’re not in the doctor’s office. Well, this study also measured the ability of the physicians to create just this sort of partnership where patients took ownership and responsibility for their health.

  The researchers believe the reason that the patients who received compassionate, patient-centered care had lower health care resource utilization was because the patients trusted their physician, believed he or she had a good understanding of them, and the physician was able to effectively manage both their anxiety and expectations. That’s because physicians who demonstrated compassionate, patient-centered care took time to ensure good information exchange, manage uncertainty, and ultimately, better understand the patient.

  That’s the power of compassion at work.

  The patients in the study above who had lower resource use didn’t need lots of extra tests to feel confident in their provider’s diagnosis and treatment plan. And that’s an important benefit of compassion. Unnecessary testing and specialist referrals are expensive for health care organizations and payers.

  Another primary care study from the University of Rochester found similar results. First, researchers collected data in two ways: through patient surveys and audio recordings of clinical encounters. Based on those, they scored each physician on his or her patient-centeredness using a validated methodology. Just as in the earlier study, they concluded that those who scored the worst also had patients with higher costs due to higher use of diagnostic tests.291

  A U.K. study on compassionate, patient-centered primary care published in BMJ (formerly known as The British Medical Journal) went even further in its conclusion.292 The authors found that when patients perceive their physician to be patient-centered, they use this as a “marker” for quality care.

  Primary care patients who had unmet expectations for a personal connection with the physician had 41 percent higher odds of referral to a specialist.

  So when they don’t experience compassion, patients tend to be less satisfied and are more likely to be referred to a specialist. In fact, primary care patients who had unmet expectations for a personal connection with the primary care physician had 41 percent higher odds of referral to a specialist after controlling for patient factors such as anxiety and the type of diagnosis.

  In a unique Canadian primary care study, researchers tested the hypothesis that patients who received compassionate, patient-centered care recover more quickly from the symptom that brought them to the doctor, report better health, and have fewer visits, tests, and referrals.289 They audiotaped each of the office encounters to score them for patient-centered communication, and then the research assistant interviewed the patient in person right after the visit. Finally, they reviewed the patient’s chart to assess the amount of follow-up care for the next two months, and conducted a follow-up assessment by telephone.

  The results? Compared to patients who did not perceive their care as patient-centered, the patients who perceived their care as patient-centered had significantly lower referrals to specialists. Specifically, the proportion of patients referred to a specialist was 51 percent lower (only 7.9 percent of patients who said their care was patient-centered versus 16.2 percent who said it was not).

  Similarly, patients who perceived their care as patient-centered had significantly less diagnostic testing performed. The proportion of patients who underwent diagnostic testing was 40 percent lower (only 14.6 percent in the patient-centered group versus 24.3 percent in the non-patient-centered group).

  Upon further testing, the researchers found that the associations between the patient perception of patient-centeredness and fewer referrals and diagnostic tests was mainly driven by the patient’s perception that “common ground had been attained.” In the subgroup that specifically expressed this perception, the results were even more impressive: The proportion of patients who were referred to specialists was 59 percent lower, while those who underwent diagnostic testing was 84 percent lower.289

  Some may worry that if physicians seem too attentive to a patient’s every worry that they might be unnecessarily racking up costs through more tests and referrals as a result. This study prove
d just the opposite: Compassionate patient-centered care reduces costs!

  Compassionate Care Drives Lower Costs through Better Adherence

  Earlier, you read about the importance of patient adherence to therapy (Chapter 5), the extent to which patients follow the treatment recommendations from their health care providers. That includes taking medication as prescribed, behavior modification (like losing weight), and following through with scheduled treatments.

  Nonadherence—when a patient doesn’t do those things—is a huge threat to public health, as discussed. That’s because disease proceeds unchecked when patients don’t take their medicine as directed or follow through on best practices their doctors recommend. Non-adherence is a complex and multidimensional problem.

  But you know what else? This preventable epidemic of unchecked disease results in a massive number of deaths and hospitalizations that have very real and staggering economic costs. As noted earlier, one estimate puts the cost between $100 billion and $300 billion per year in the U.S. alone.194, 196

  And as you learned, compassion effectively promotes and improves patient adherence. Therefore, some of the $100 to $300 billion is up for grabs as a way to reduce overall costs in healthcare.

  There’s no need to spend massive amounts of money to develop and bring new drugs to market if patients don’t take them. What about using compassion to convince people to take the drugs we already have instead? This simple shift in care has the potential to save billions of dollars.