Patients who express satisfaction with the quality of the hospital care they received are not necessarily receiving high-quality care.

Or so says a new study in the journal JAMA Internal Medicine.

The study found that many patients who expressed satisfaction with the hospital care they received did not necessarily understand the care they had undergone and the care they would require in the future, casting doubt on the assumption that satisfaction equates with quality.

Patient satisfaction is a major component of Medicare’s value-based purchasing program, and hospitals can be rewarded or penalized based on their patients’ satisfaction as measured in surveys.

The National Association of Urban Hospitals (NAUH) has expressed the same concern over the years, beginning with a 2012 letter to the Centers for Medicare & Medicaid Services (CMS) about its proposed use of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey as a means of measuring patient satisfaction as part of determining whether hospitals were to be rewarded or punished financially as part of Medicare’s value-based purchasing program.  In that letter, NAUH wrote that it

…has serious reservations with the direction in which CMS is taking the HCAHPS survey as a tool for evaluating the effectiveness of hospitals and adjusting Medicare payments to those hospitals.  We believe the survey is biased against large urban hospitals in several respects.  In some instances, we believe the survey’s questions are biased against large urban hospitals; in others, we believe the manner in which the survey’s findings are weighted is biased against large urban hospitals.

First, we believe some of the survey’s questions are biased against large urban hospitals.  We think it is inappropriate, for example, to compare the degree of quietness of a seventy-five-year-old hospital with semi-private rooms located in a congested urban area with that of a new facility with private rooms located on a sylvan, multi-acre campus set well off any major thoroughfares.

Second, we believe the manner in which the responses to some questions will be weighted is biased against large urban hospitals.  We think it is unfair, for example, to downgrade the survey results from the kinds of patients urban safety-net hospitals serve in especially high numbers and proportions, such as maternity patients and those for whom English is not their native language.  Similarly, the American Hospital Association has found that more seriously ill patients are more likely to respond with negative observations when completing the HCAHPS survey.  Urban safety-net hospitals care for such patients in disproportionate numbers and believe this situation calls for appropriate adjustment.  In addition, CMS’s own data shows significantly lower scores in more urbanized states – the very places in which most urban safety-net hospitals can be found.  Consequently, NAUH believes more should be done to adjust HCAHPS scores appropriately before they are used to influence Medicare payments to hospitals.

Because of these challenges, NAUH urges CMS to reduce the weight given to HCAHPS results in the value-based purchasing program.

NAUH recognizes the importance of hospitals providing care that meets patients’ expectations but believes that before undertaking the major step of adjusting Medicare payments to hospitals based on the perception of those patients, a better and more realistic approach needs to be taken to using and adjusting the results of HCAHPS surveys.

Learn more about the study in this Fierce Healthcare article.  Find a link to the study itself here, on the JAMA Internal Medicine site, and read an interview with the study’s principal investigator here.