Patient Satisfaction: The New Rules of Engagement

Patient satisfaction has garnered new attention as an indicator of provider performance and an important dimension of value-based health care under the Affordable Care Act (ACA). Defined in any number of ways, it is often publicly reported to help patients choose among health care providers.

This month, patient satisfaction takes on even greater importance as ACA provisions set to begin October 1, 2012, tie patient satisfaction to Medicare reimbursement, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. HCAHPS scores reflect patients’ perspectives on several aspects of care: communication with doctors and nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment—and are estimated to place at risk an average of $500,000 to $850,000 annually per hospital.(1)There’s a lot riding on patients’ perceptions of the health care experience, our satisfaction with the care we receive. But what do we really know about patient satisfaction, its relationship to patient outcomes and cost—and just what is it we are rewarding?

Benefits and Costs of Patient Satisfaction

There are plenty of proven benefits to keeping patients satisfied. Satisfied patients are more likely to adhere to prescribed treatment plans, maintain an ongoing relationship with a health care provider and realize subsequent benefits relating to health outcomes. Providers interests are also well served by satisfied patients, and may realize improved volume related to community reputation, reduced malpractice claims, more satisfied staff (and related decreased turnover), and improved efficiency. (2) Ironically, satisfied patients may not receive satisfactory care. In fact, they may receive more care, at greater expense, and often of poorer quality than their dissatisfied counterparts. According to a recent Archives of Internal Medicine study of nearly 52,000 individuals, higher patient satisfaction was associated with less emergency department use but greater inpatient use, higher overall health care and prescription drug expenditures, and more deaths.

These apparent downsides for patients can translate to increased revenue from increased patient volume and service utilization. In fact, Press Ganey reports that a hospital with $120 million annual revenues can improve patient satisfaction and realize an estimated $2.2 million to $5.4 million in additional revenue annually.(3) The also report that improving patient satisfaction can reduce malpractice litigation and associated costs, which can be substantial: an estimated $53,000 in case preparation costs and $173,000 in payments for each lawsuit.

Patient Satisfaction is in the Eye of the Beholder

Patient satisfaction is widely recognized to be multi-dimensional and personal. It is the core of patient-centered care. Research shows that how we perceive and experience our health care reflects socio-demographic characteristics such as education, age, race/ethnicity, income and health status. Studies consistently show that younger patients are less satisfied than older patients, patients with higher education and income, and those who are sicker tend to be more satisfied than patients who consider themselves healthier or less well off. (4) Regional differences, with patients in the South and Midwest reporting higher satisfaction, and differences between small and large hospitals have also been reported. (5)

These variations have raised questions regarding whether it is fair to reward providers for satisfied patients and penalize them for dissatisfied ones. (6) Safety net hospitals are especially concerned about patient satisfaction as an indicator of performance. These facilities serve needy patients and typically struggle to meet patients’ expectations in areas including communication and pain management. (7)

Patient Satisfaction and Patient Engagement

It’s not enough for patients to be merely satisfied with their health care. Our expectations and perceptions of the patient experience vary widely, but at the end of the day what we seek is health care that is patient-centered: care that meets our needs. Patient-centered care requires patient engagement and self-efficacy, our active participation in our health and disease management.

In a recent blog, Ian Worden described the difference between patient experience and patient engagement. He explains,

Whereas the patient experience is based on the patient’s perception of quality, patient engagement is based on the patient’s active and sustained participation in managing their health. The patient experience is about perceptions and patient engagement is about actions and behaviors. A patient can conceivably be satisfied with their health care experience while having minimal engagement.

Jesse Gruman, president and founder of the Center for Advancing Health, gets at the essence of patient engagement in defining it as “actions individuals must take to obtain the greatest benefit from health care services available to them,” or acting to the best of our ability to find and make good use of the health care available to us. (8) As patients, we are responsible consumers driving our health and wellbeing.

Patient engagement, still emerging as a tool for health improvement, leads to better health outcomes as we take action to change or maintain productive health behaviors. According to Judith Hibbard, Ph.D., expert on patient activation and engagement, engaged patients are less likely to use emergency room care, less likely to be readmitted to hospitals within 30 days of discharge, and in one Kaiser Permanente study of diabetic patients, had fewer hospitalizations than those who were less engaged.(9)

The New Rules of Engagement

Like patient satisfaction, patient engagement goes by many names and definitions. At its center is the concept of taking an active role in our health and health care. It can be measured using tools like the Patient Activation Measure (PAM) developed by Hibbard and colleagues. This 13-question survey is used to place patients in one of four categories, from those who are least active and confident in addressing their health needs to those who are highly activated and engaged in managing their health and wellbeing. The PAM helps to identify a patient’s engagement level as a tool for improving activation for health and wellness. It is a tool to advance value-based health care.

The new rules of engagement—patient engagement—open the door to healthier lifestyles and overall improvements in health and wellbeing. Indeed, while Medicare is trying to incentivize health care providers to pay more attention to the overall patient experience rather than simply getting the clinical diagnosis “right”, the patient experience itself is profoundly shaped by how each individual conceptualizes health and understands how medical treatment may help (or hurt) their personal health goals. Individuals who are active and engaged in their health care are also active participants in maintaining and managing their health. This is where the true “value”, from both a personal and economic standpoint, can be found: By empowering patients to understand that providers are not merely professionals to see when one gets “sick”, but valuable partners that can help provide advice and tools for individuals to take charge and achieve health outside the clinical setting. To realize the value this partnership can bring we first need to understand how to activate and maintain our engagement. That’s the hardest part of all.

(1)  Buhlman, N. ,& N. Matthes. (2011). The time to prepare for value-based purchasing is now. White Papers for Hospitals.

(2)   Carroll, P., ed. (2012, Winter). Satisfied patients are money in the bank. Clinical Update.

(3)   Hall, M. F. (2008, October). Looking to improve financial results? Start by listening to patients, Healthcare Financial Management, 76-80.

(4)   Rothrock, S. (2012, September 20). Higher patient satisfaction associated with more cost, more treatments, and more deaths. Health News Observer. Retrieved from http://www.healthnewsobserver.com/articles/detail/patient-satisfaction-associated-with-more-cost-more-treatments-and-more-dea

(5)   Carroll, P., ed. (2012, Winter). Satisfied patients are money in the bank. Clinical Update.

(6)   Schoenfelder, T. (2012). Patient satisfaction: A valid indicator for the quality of primary care? Primary Health Care, 2, 4. Retrieved from http://dx.doi.org/10.4172/2167-1079.1000e106 .

(7)   O’Reilly, K. B. (2012, August 6). Coming wave of Medicaid patients will test quality at safety net hospitals. Retrieved from http://www.ama-assn.org/amednews/2012/08/06/prl20806.htm.

(8) Gruman, J.  (2012, February 8). Patient Engagement!: Our skin is in the game. [Web log post]. Retrieved from http://blog.preparedpatientforum.org/blog/2012/02/patient-engagement-our-skin-is-in-the-game.

(9)   Simmons, J. (20120, May 11). Patient engagement occurs one step at a time. HealthLeaders Media. Retrieved from http://www.healthleadersmedia.com/enewsletter/web-version/HealthLeadersMediaDaily_12_March2010.html.

Holly Korda, Ph.D. is the deputy director for strategy and growth at the Altarum Institute. The post first appeared on the Altarum Health Policy Forum.

11 replies »

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  3. I personally believe that every patient who steps in a health care facility whether its the physicians office or a hospital deserves the best possible experience- They did not ask to be a patient
    We should take very good care of thrm

  4. Steve

    Seems like its time for employee training for patient experience enhancement and HCAHPS. You keep your competent employees but provide them required training and tools at the same time .

  5. Value based purchasing based on higher HCAHPS scores; financial incentives and punishment tied to patient satisfaction would definitely benefit resourceful healthcare systems. Those Health systems have enough dollars to spend on their quality improvement initiatives but what about resource less community health systems and/or rural health systems ? would those be the once hard hit by the Value based purchasing ?

  6. Press Ganey has created an issue for me. On the labor floor, my guys pretty consistently run in the 5%-10% percentile on their Press Ganey scores. Qe also score in the 90s for quality. So, do I fire a few grumpy people and hire a few more nice, but less competent folks?


  7. It depends on how the survey defines ‘patient satisfaction’. If it asks what the wait time to see the provider, yet does not even ask or validate if the diagnosis was correct or the treatment effective, is ‘satisfaction’ really meaningful? I think the Annals study points out that there is more to ‘satisfaction’ than we can safely generalize. Primum non nocere.

  8. “There are plenty of proven benefits to keeping patients satisfied”


    More hospitalizations, higher costs, greater mortality.