Viewpoint
2020; Lippincott Williams & Wilkins; Volume: 42; Issue: 3B Linguagem: Inglês
10.1097/01.eem.0000658332.57144.b4
ISSN1552-3624
Autores ResumoFigureFigureStudies show that patients happy with their health care are more likely to be compliant with treatment plans and medications. (BMJ Open. 2013;3[1], pii: e001570; http://bit.ly/39Yz77Y.) The prevailing view is that patients' satisfaction with their health care leads to improved well-being and therefore improved compliance and health. Health care was a $3.5 trillion business in 2017, 17.9 percent of the U.S. gross domestic product (GDP). (CMS. Dec. 11, 2018; https://go.cms.gov/2TlqgH0.) The Centers for Medicare and Medicaid Services had no trouble then “linking financial incentives to patient experience scores as part of the Hospital Value-Based Purchasing program authorized by the Affordable Care Act,” rewarding or penalizing hospitals based on those scores. (AMA J Ethics. 2015;17[7]:616; http://bit.ly/3c4reQi.) Because this was done to reduce the impact of health care spending on the GDP, patient satisfaction became the imperative and health care became more patient-centric. (NEJM Catalyst. Jan. 1, 2017; http://bit.ly/2w2J8SY.) Reimbursement hinges more and more on fee-for-quality than fee-for-service, and quality care has become a financial imperative. (Press Ganey. Jan. 12, 2015; http://bit.ly/2HWQE4o.) Assessment of patient satisfaction is fraught with many problems, however. (Becker's Hospital Review. Dec. 14, 2018; http://bit.ly/2Tgs0kt.) Patient satisfaction isn't an objective measure of care quality (NEJM Catalyst. Jan. 1, 2017; http://bit.ly/2w2J8SY), and some in health care have reported that patient satisfaction scores are useless. (MedPage Today. Dec. 6, 2017; http://bit.ly/2HXgNQB.) A patient's report of satisfaction can be nebulous. What determines satisfaction? Handholding, empathy, acquiescing to patients' demands, and good care all play a part in elevating satisfaction scores. Patients can report receiving good care but have no idea what good care is. A New York cardiologist, who defrauded the government and private insurers of $19 million by ordering unnecessary and possibly dangerous tests for patients, had previously received three Healthgrades quality awards. (Physician's Weekly. June 24, 2013; http://bit.ly/2wEL6ZZ.) He even employed unlicensed and unqualified personnel who treated patients, but he always got very good to excellent reviews. Refusal of patients' requests for medications, referrals, and laboratory tests has resulted in reduction in patient satisfaction scores for providers. (MedPage Today. Dec. 6, 2017; http://bit.ly/2HXgNQB.) Besides empowering patients to determine a health facility's and providers' reimbursements, patient satisfaction has generated other businesses. As expected with capitalism, consulting companies were created to teach health care professionals how to increase their patient satisfaction scores. AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank you) became a famous mantra. Perception in medicine is reality. You are guaranteed almost maximum reimbursement if you smile, sit, and hold hands with the patient regardless of the care you provide. Other companies have offered to improve a provider's poor online health rating. Consultants have devised performance metrics to improve patient satisfaction. In the emergency department, evaluating and discharging an arbitrary number of low-acuity patients in less than 90 minutes is mandated. This means that higher-acuity patients get delayed evaluations and treatments or delayed re-evaluations to comply with the metric. Is this really good health care? Many providers cannot take a decent meal break while trying to keep up with these metrics. Let's be real, patient satisfaction is all about reimbursement. Why does it seem that the onus is only on the health care service or provider and not on the patients to have them take ownership of their health? There is a prevailing feeling that patients are victims. Whatever affliction they have is never their fault. They are victims of society and life in general. There may be some historical truth to that. Adam in the Garden of Eden had an addiction to the fruit of the tree of life, but he did not do much besides yearn for it. Adam suffered the double whammy. Not only did he have an addictive gene, the Devil also corrupted him and made him eat the fruit. Cain was also afflicted with a bad gene pool. He was addicted to violence. Instead of living in the idyllic Garden of Eden, they were now living in a barren wasteland, without much choice in mates. Is it any wonder that Cain would kill Abel? Besides, the Devil made him do it. A social drinker has too much to drink at the office party and decides to drive herself home. She causes an accident where passengers in the other vehicle die. It is not her fault. She has an addictive gene. And the Devil made her do it. There is a big warning label on packs of cigarettes that highlights the dangers of smoking. But if someone ignores the warning and takes up smoking, it is because that person has an addictive gene. Besides, the Devil made him do it. And so on. It is amazing how people are easily excused for their behavior. We are all addicts, it seems. People are addicted to alcohol, sex, smoking, food, sports, activities that cause an adrenaline rush, money, television, cell phones, social media, mind-altering substances, shopping, cosmetic surgery, tanning, hate, violence, cults, politics, and sedentary lifestyles. We may even be addicted to the air we breathe. But when these people use the health care system, guess who gets blamed for their unfortunate circumstance? The health care provider, of course! Look at patients with congestive heart failure. The government in its infinite wisdom decides that it will not reimburse for any 30-day readmission to the hospital for CHF patients. The first hospital stay was appropriate and the patient was managed correctly, but he goes home and is noncompliant with his diet or medications. He decompensates and returns to the ED in respiratory distress in less than 30 days. Who does the government penalize for this? Not the patient but the health care industry! It is never the patient's fault. A study showed that the death rate of patients with CHF has increased since the implementation of this policy. (Modern Healthcare. Nov. 13, 2017; http://bit.ly/393Y1Da.) What is the effect on the provider? Burnout, depression, and suicide are important issues for physicians. Physicians are now slaves to metrics and patient satisfaction, work longer hours without remunerations, and deal with an electronic medical record system that is not always physician-friendly. Almost 46 percent of physicians, especially those in primary and emergency care, were exhibiting at least one symptom of burnout, and a 2012 study found that almost 30 percent of primary care physicians aged 35 to 45 were planning to leave their practice within five years. That number was almost 52 percent in those over 50. (ONYX M.D. http://bit.ly/2w1jONk.) Doctors' suicide rate is reportedly the highest of any profession, and is more than twice the rate of the general public. (WebMD. May 8, 2018; https://wb.md/2sHBB6Z.) Inadequate treatments and job stress appear to be the major factors. (Gen Hosp Psychiatry. 2013;35[1]:45; http://bit.ly/2Ppomnz.) Instead of addressing the underlying issues, “wellness” in medicine is now the trend. The message to the physician is that it is your fault if you feel burned out, depressed, or suicidal. You should be practicing meditation, doing deep breathing, exercising, doing yoga, and focusing on your spirituality and family. Do not think of rocking the boat by questioning policy; just focus on your wellness. No one will argue that wellness is beneficial to everyone, but wellness in health care is more like putting a bandage on self-inflicted wounds. Let's not worry about the cause of the wound; the bandages will help them heal until the next wound is inflicted. Health care has become a political football where economics is the biggest driver. Others have said medicine is “a nationwide system of financial obfuscation, in which the ruling denizens are huge corporate entities that control scores of hospitals or health insurance for millions of subscribers... who are paying exorbitant premiums to support thousands of vendors, and have no idea what they are paying for.... And physicians... now find themselves no more than compliant (and replaceable) cogs in the machinery.” (Baltimore Sun. Aug. 25, 2018; http://bit.ly/2Psb3mi.) Patient-centric consumerism is the norm, yet the consumer metaphor wrongly assumes that health care is a market in the usual understanding of that term. (Health Aff[Millwood]. 2019;38[3]:368.) The providers, under the weight of this policy, are becoming more depressed and suicidal. Political parties spew notions of health care as their major focus while doing nothing to improve the system. No one can deny that health care providers do the utmost for patients. They may not always cater to patients' unreasonable demands, but they try to do what is medically appropriate to improve the health and well-being of patients. Yes, there are a few bad apples in the profession whose focus is on profit and not patients, but they are the exceptions to the rule. Disclaimer: This article expresses only the views of the author and those cited. It has not been sanctioned or reviewed by his employer, any subsidiary of his employer, or anyone who contracts with his employer. He has no financial or other association with anyone or any organization cited in the article.
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