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Patient Experience

Understanding how policy changes may affect patient experience is important because it provides insight into the extent to which the change will be evaluated as positive or negative from the perspective of a key stakeholder. Many prior efforts to reform the health care system have failed because of consumer response to the change.

How Is Patient Experience Measured?
Who Routinely Measures Patient Experience?
How Do Patients Assess Health Plans?
How Do Patients Assess Hospitals?
How Do Patients Assess Medical Groups?
How Do Assessments of U.S. Patients Compare to Assessments of Patients in Other Countries?
What Demographic Characteristics Are Associated with Differences in Patient Experience?
What Are the Trends in Patient Experience?
References
How Is Patient Experience Measured?Save to My Compare

Patient experience is measured by surveying consumers who have had some contact with the health care system. For example, patients enrolled in health plans are surveyed annually about a variety of encounters they may have had with physicians, office staff, insurance company representatives, and other providers. Patients who have been hospitalized or used the emergency room are surveyed shortly after their discharge. Patients may also be surveyed when they participate in novel programs, such as demonstration projects or research projects, to learn more about how their experiences compared with standard methods of delivering care.

Since the mid—1990s, considerable efforts have been made to standardize the surveys used to assess patients' experiences in order to improve the ability of managers and policymakers to compare the performance of different entities. The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys, developed under funding from the Agency for Healthcare Research and Quality (AHRQ), are the most widely used patient experience surveys in the United States. The CAHPS family includes surveys appropriate for assessing health plans, hospitals, medical groups, hemodialysis facilities, and nursing homes as well as care for patients with mobility impairment. These surveys are characterized by standard wording of questions; standard response choices; and detailed methods for selecting samples, fielding surveys, and analyzing results.

Patient experience surveys used in research or evaluation projects are generally constructed to address specific issues of interest for the study. These surveys typically use standard methods for writing questions, developing responses, identifying a sample, fielding the survey, and analyzing results. However, differences in the choices made by developers frequently make it difficult to compare results across projects. Nonetheless, these surveys often offer the best insight into how patients might respond to a policy change.

Who Routinely Measures Patient Experience?Save to My Compare

A number of groups routinely collect data and report the results of patient experience surveys. AHRQ and the Centers for Medicare & Medicaid Services (CMS) are the two government agencies that compile information on patient experience. In the private sector, the National Committee for Quality Assurance (NCQA) collects information on health plans; the Commonwealth Fund collects information comparing the experience of U.S. patients with those of patients in a number of developed countries; a business group in California (Pacific Business Group on Health) and a collaborative in Massachusetts (Massachusetts Health Quality Partners) collect and report results on medical groups.

How Do Patients Assess Health Plans?Save to My Compare

Patients' experiences with health plans are grouped into some key areas identified in research conducted with patients to determine what aspects of care were most important to them. Consumer data from the CAHPS survey are presented in four summary or composite measures:

  • Getting needed care
  • Getting care quickly
  • How well doctors communicate
  • Health plan information and customer service.

Getting needed care. A key expectation for many patients is the ability to get medical care when they believe they need it. Data for commercial health plan members were obtained from NCQA, data for adult Medicaid recipients were obtained by state Medicaid agencies from individual health plans, and data for Medicare were collected from beneficiaries by CMS. Figure 1 shows that Medicare managed care beneficiaries were more likely to say that they always received needed care than were adult enrollees in commercial or Medicaid plans.

Figure 1. Getting Needed Care

Figure 1: Getting Needed Care SOURCE: AHRQ, 2008. NOTE: Response distributions may not sum to 100 percent because of rounding. Click to Zoom

Getting care quickly. Patients are not only interested in getting care they need, they value being able to obtain it in a timely manner. Getting care quickly means that patients can make appointments without significant delays, and once they arrive for medical services, they receive care without significant wait times. Figure 2 shows that Medicaid enrollees are more likely than Medicare or commercial enrollees to report that they never or only sometimes get needed care quickly.

Figure 2. Getting Care Quickly

Figure 2. Getting Care Quickly SOURCE: AHRQ, 2008.NOTE: Response distributions may not sum to 100 percent because of rounding. Click to Zoom

How well doctors communicate. Patients' overall experiences with doctors are shaped by communication style (e.g., respectful, patient) and content (e.g., thoroughness, clarity) and both contribute to the likelihood that a patient will understand and be able to follow treatment recommendations. Figure 3 shows that Medicaid enrollees are twice as likely as Medicare or commercial enrollees to report that their doctors' communication style and content never or only sometimes meet their needs.

Figure 3. How Well Doctors Communicate

Figure 3. How Well Doctors Communicate SOURCE: AHRQ, 2008. NOTE: Response distributions may not sum to 100 percent because of rounding. Click to Zoom

Health plan information and customer service. Not surprisingly, health care consumers today spend more time interacting with medical office and health plan staff than they do interacting with physicians. From making appointments to handling billing issues, these individuals play a major role in a patient's experience and potentially can strongly influence a patient's decisions to remain enrolled in a particular health plan or to continue receiving care at a particular medical facility. Figure 4 shows that Medicare beneficiaries are more likely to report that they always or usually get the information they need or the customer service they expect.

Figure 4. Health Plan Information and Customer Service

Figure 4. Health Plan Information and Customer Service SOURCE: AHRQ, 2008. NOTE: Response distributions may not sum to 100 percent because of rounding. Click to Zoom
How Do Patients Assess Hospitals?Save to My Compare

In 2006, CMS began requiring hospitals to report routinely on the experiences of patients who have been discharged from the hospital. The categories on which hospitals report are

  • communication with nurses
  • communication with doctors
  • responsiveness of hospital staff
  • pain management
  • communication about medicines
  • cleanliness of hospital environment
  • quietness of hospital environment
  • discharge information
  • overall hospital rating
  • likelihood of recommending the hospital.

Information about the performance of individual hospitals is available from CMS on the Hospital Compare Web site (http://www.hospitalcompare.hhs.gov/). Figure 5 shows that patients rate their experiences with receiving needed information at discharge and their communication with physicians most favorably and their experience regarding communication about their medications least favorably.

Figure 5. Patient Experiences in Hospitals: National Averages

Figure 5. Patient Experiences in Hospitals: National Averages SOURCE: Summary of HCAHPS Survey Results, 2009.Click to Zoom

Statewide averages are reported on the Hospital CAHPS online Web site (http://www.hcahpsonline.org). Figure 6 shows the highest and lowest performance across the states compared with the national average. For example, patients' overall hospital ratings range from 54 (in Hawaii) to 72 (in South Dakota).

Figure 6. Range of State Average Performance on Patient Experiences

Figure 6. Range of State Average Performance on Patient Experiences SOURCE: Summary of HCAHPS Survey Results, 2009.Click to Zoom

Figure 7 shows the range of scores from individual hospitals on the patient experience measures. The figure shows the large differences across all categories between the top and bottom performing hospitals.

Figure 7. Range of Hospital Scores on Patient Experiences

Figure 7. Range of Hospital Scores on Patient Experiences SOURCE: Summary of HCAHPS Survey Results, 2009. Click to Zoom
How Do Patients Assess Medical Groups?Save to My Compare

California and Massachusetts systematically report patient experience at the level of the medical group.

The Pacific Business Group on Health. The Pacific Business Group on Health (PBGH), founded in 1989, is a coalition of 50 large purchasers of health care coverage in California that provide coverage to more than 3 million employees, retirees, and dependents (www.pbgh.org). A nonprofit organization, PBGH supports efforts to gather standardized information about the performance of physicians and medical groups, and to use this information to drive quality improvement and accountability.

Among the data collection tools used by PBGH and collaborating organizations is the Patient Assessment Survey, which asks consumers about access to primary and specialty care, patient–doctor communication, overall ratings of care, and counseling about preventive care. The results are reported to PBGH members and are also posted on the Web site of the California Office of the Patient Advocate (http://opa.ca.gov/). Clinical care is assessed by comparing each medical group's patient records to a set of national standards for quality of care. Patients are also asked to rate groups with regard to communication, coordination of care, the helpfulness of office staff, and receiving timely care and service. For example, Figure 8 shows patient ratings for timely care and service for medical groups in Sacramento County in 2007.

Figure 8. Patient Ratings of Timely Care and Service for Medical Groups in Sacramento County, 2007

Figure 8. Patient Ratings of Timely Care and Service for Medical Groups in Sacramento County, 2007 SOURCE: State of California, not dated. Click to Zoom

Massachusetts Health Quality Partners. The Massachusetts Health Quality Partners (MHQP) is a coalition of physicians, hospitals, health plans, purchasers, consumers, and government agencies collaborating to improve quality of health care services in Massachusetts (http://mhqp.org/). Established in 1995, MHQP uses clinical data to compare how different medical groups in the State treat the same type of illness or health condition. MHQP also gathers information about patient experience by surveying patients on seven measures: how well doctors communicate with their patients, coordinate their care, know their patients, and give preventive care and advice, and patients' perceptions of their ability to get timely appointments and care, good care from other doctors and nurses in the office, and helpful service from office staff.

Table 1 shows results of patient experience surveys for four medical groups in Massachusetts in 2007 for the first four of these measures.

Table 1. Ratings of Four Dimensions of Patient Experience in Massachusetts Medical Groups, 2007
Name of medical group Communication Coordination of care Knowing their patients Giving preventive care and advice
Charles River Medical Associates (pediatrics) * * * * * * – – * * * * * * * –
Charles River Medical Associates 571—Framingham (adult medicine) * * * * * * * – * * * – * * – –
Charles River Medical Associates 83—Natick (adult medicine) * * * – * * – – * * – – * * – –
Charles River Medical Associates 67—Hodgson (adult medicine) * * * – * – – – * * – – * * – –
SOURCE: MHQP, not dated. NOTES: The star ratings for each measure show how a medical group compares to all the medical groups in the state that were part of the MHQP survey:
  • 4 stars—the medical group did better than at least 85 percent of the medical groups in this survey.
  • 3 stars—the medical group did better than at least 50 percent of the medical groups in this survey.
  • 2 stars—the medical group did better than at least 15 percent of the medical groups in this survey.
  • 1 star—the medical group did less well than at least 85 percent of the medical groups in this survey.
How Do Assessments of U.S. Patients Compare to Assessments of Patients in Other Countries?Save to My Compare

The Commonwealth Fund (http://www.commonwealthfund.org/) regularly surveys the experiences of patient in several countries. The 2008 survey focused on patients who had at least one chronic condition (arthritis, cancer, depression, diabetes, heart disease, hypertension, lung problems) and was conducted in eight countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States). Figure 9 provides highlights of the findings. Because the questions focus on problems, a higher score represents poorer performance. Patients with chronic illnesses in the United States report more problems with access problems related to cost and with having received wasteful care than patients in any of the other seven countries. These same patients report the best experiences among the countries surveyed with waiting times to see a specialist. In most other categories, U.S. performance is in the middle.

Figure 9. International Comparisons of Chronically Ill Patients' Experiences with Care

Figure 9. International Comparisons of Chronically Ill Patients' Experiences with Care SOURCE: Based on data from Schoen et al., 2009. Click to Zoom
What Demographic Characteristics Are Associated with Differences in Patient Experience?Save to My Compare

Research studies have come to different conclusions regarding the connections between patient satisfaction and race, ethnicity, and gender (Roohan et al., 2000). Generally, Asian Americans have tended to report lower levels of satisfaction than other racial or ethnic groups. Although blacks may receive worse care overall than whites, they tend to report comparable (or better) experiences with care, possibly because of differences in expectations. Hispanics, too, have at times reported higher levels of care (Roohan et al., 2000). Yet other studies have found no differences between whites and minorities (Roohan et al., 2000). One study of patient experience using CAHPS data has identified language barriers as being responsible for a large part of racial and ethnic disparities in care (Weech-Maldonado et al., 2001).

Other factors besides race and ethnicity have also been studied for associations with patient satisfaction. For example, healthy members of Medicaid managed care programs have been found to be at least as satisfied with their plans as healthy members of commercial managed care programs (Roohan et al., 2000). Older, less educated, and healthier patients all tend to report higher levels of satisfaction, although some studies have not found any such connection between satisfaction and socioeconomic status (Roohan et al., 2000). Consistent with the finding that healthier patients are in general more satisfied with their care, some have suggested focusing quality improvement efforts on "a small population of intensive health system users" in order to "control costs and improve care" (Blendon et al., 2003).

Results from the CAHPS Health Plan survey have shown significant differences with health plans in the experience of different racial and ethnic groups. These differences between groups exist within plans, and not just between different plans (Weech–Maldonado et al, 2004). The disparities are persistent, are independent of education and income (Haviland et al., 2005), and are large enough to suggest real opportunities for quality improvement (Weech–Maldonado et al., 2004; Haviland et al., 2006). Figures 10 and 11 illustrate small but statistically significant differences in ratings among different racial groups.

Figure 10. Global Ratings of Care, by Racial/Ethnic Group (National CAHPS Benchmarking Database 2.0)

Figure 10. Global Ratings of Care, by Racial/Ethnic Group (National CAHPS Benchmarking Database 2.0) SOURCE: Based on data from Lurie et al., 2003, p.506. Click to Zoom

Figure 11. Composite Scores of Care by Racial/Ethnic Group (National CAHPS Benchmarking Database 2.0)

Figure 11. Composite Scores of Care by Racial/Ethnic Group (National CAHPS Benchmarking Database 2.0) SOURCE: Based on data from Lurie et al., 2003, p. 506.Click to Zoom
What Are the Trends in Patient Experience?Save to My Compare

Because of the lack of time series data on the patient experience of care, it is difficult to identify trends and make predictions about the future. Still, it is possible to say that increasing costs and decreasing access may put pressures on the quality of patients' experiences, while reforms and increasing awareness of the topic may help.

ReferencesSave to My Compare
  • Agency for Healthcare Research and Quality (AHRQ), 2008 CAHPS® Health Plan Survey Chartbook: What Consumers Say About Their Experiences with Their Health Plans and Medical Care, Rockville, Md., National CAHPS® Benchmarking Database, AHRQ Publication No. 08-CAHPS001-EF, October 2008. As of : https://www.cahps.ahrq.gov/content/NCBD/Chartbook/HEALTHPLAN08/index.html
  • Blendon RJ, Schoen C, DesRoches C, Osborn R, Zapert K, "Common Concerns Amid Diverse Systems: Health Care Experiences in Five Countries," Health Affairs, Vol. 22, No. 3, May/June 2003, pp. 106–121.
  • Haviland MG, Morales LS, Dial TH, Pincus HA, "Race/Ethnicity, Socioeconomic Status, and Satisfaction with Health Care," American Journal of Medical Quality, Vol. 20, No. 4, July/August 2006, pp. 195–203.
  • Lurie N, Zhan C, Sangl J, Bierman AS, Sekscenski ES, "Variation in Racial and Ethnic Differences in Consumer Assessments of Health Care," American Journal of Managerial Care, Vol. 9, No. 7, July 2003, pp. 502–509.
  • Massachusetts Health Quality Partners (MHQP), Quality Reports, Watertown, Mass., not dated. As of August 27, 2009: http://www.mhqp.org/default.asp?nav=010000
  • Roohan PJ, Conroy MB, Anarella JP, Butch JM, Gesten FC, "Commercial Managed Care Plans Leaving the Medicaid Managed Care Program in New York State: Impact on Quality and Access," Journal of Urban Health, Vol. 77, No. 4, December 2000, pp. 560–572.
  • Schoen, Cathy, Robin Osborn, Sabrina K.H. How, Michelle M. Doty, and Jordon Peugh, "In Chronic Condition: Experiences of Patients with Complex Health Care Needs, In Eight Countries, 2008," Health Affairs [Epub, November 13, 2008], Vol. 28, No. 1, 2009, pp. w1–w16.
  • State of California, California Office of the Patient Advocate, Health Care Quality Report Card, not dated. As of August 25, 2009: http://opa.ca.gov/report_card/medicalgroupcounty.aspx
  • Summary of HCAHPS Survey Results, Baltimore, Md.: Centers for Medicare & Medicaid Services, March 2009. As of August 24, 2009: http://hcahpsonline.org/executive_insight/Files/Report_HEI_March%203-31-2009.pdf
  • Weech–Maldonado R, Elliott MN, Morales LS, Spritzer K, Marshall GN, Hays RD, "Health Plan Effects on Patient Assessments of Medicaid Managed Care Among Racial/Ethnic Minorities," Journal of General Internal Medicine, Vol. 19, No. 2, February 2004, pp. 136–145.
  • Weech–Maldonado R, Morales LS, Spritzer K, Elliott M, Hays RD, "Racial and Ethnic Differences in Parents' Assessments of Pediatric Care in Medicaid Managed Care," Health Services Research, Vol. 36, No. 3, July 2001, pp. 575–594.

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