The Mandate to Measure Patient Experience

In an effort to ensure that the quality of medical care in the United States is commensurate with the societal and opportunity costs of providing this care, the health care industry has been compelled to place a greater emphasis on value.1 “Bending the cost curve” was popular jargon justifying the passage of the Affordable Care Act and the resultant public policy redefining health care. Experts posit that health care systems will reorganize around new payment models linking payment and resource allocation to quality metrics.2 In this article, we (1) present the fiscal and financial impetus for concentrating on health care value, (2) discuss how an influential survey quantifying patient experience in the perioperative period inadequately assesses anesthesiologists’ value, and (3) emphasize the importance of organizationally transforming anesthesiology to display our actual value as a comprehensive perioperative care team. For clarification, when “anesthesiology” is written, it refers to the profession; when “anesthesiologist” is written, it refers to the individual; and when “anesthesiologists” is written, it refers to the entire group of anesthesiologists contributing to a patient’s perioperative care. FISCAL POLICY AND FINANCIAL EFFECTS ON HEALTH CARE As health care systems improve performance and reduce waste to survive, 2 stakeholders must actively lead: patients and clinicians. Soon, all medical specialties will need to provide quantifiable evidence of value (outcomes relative to cost) to patients.3 Clinicians must ensure that the elimination of “waste” through cost-saving measures does not compromise our ability to provide high-value care to our patients (Fig. 1).Figure 1: The quality of anesthesia care is dependent on the resources invested. The black curve represents the actual value of anesthesia care. Increased resource investment improves anesthesia quality; however, point “pav” resides beyond the point of diminishing marginal returns, and continued resource investment only slightly increases quality. The gray curve represents the capacity of current health care metrics to quantify the quality of anesthesia care: these metrics appear to underestimate the growth and total value of anesthesia care. If a health care system expended “$” resources resulting in “pav” quality, it would be receiving a high actual value of anesthesia care at a point where continued resource investment would add little to anesthesia quality. If this health care system pursues a cost-savings strategy based on the current quantitative anesthesia quality measures, it may identify “pqv” as an efficient value because the quantifiable value curve has a point of diminishing returns that occurs at a lower level of resource investment than the actual value of anesthesia care. Thus, resource expenditure would be reduced to “$*.” Such a choice in resource expenditure will marginally affect the quantifiable quality (ΔQqv) but may significantly reduce the actual quality of anesthesia care delivered to patients (ΔQav).The Affordable Care Act created the Value-Based Payment modifier that financially penalizes or incentivizes Medicare reimbursements based on the value of care delivered to patients. Thirty percent of the Value-Based Payment modifier is patient experience metrics. The Centers for Medicare and Medicaid Services (CMS) stated that patient experience metrics for the perioperative period are a priority.a Notably, the Medicare Access and CHIP Reauthorization Act of 2015 mandated that, beginning in 2019, the Value-Based Payment modifier will be folded into a new system of payment (Merit-Based Incentive Payment System).b Although Merit-Based Incentive Payment System-specific rules have yet to be written, clinicians will be scored across several quality domains; rewards or penalties will be based on whether a score is above or below a threshold set by the Secretary of the Department of Health and Human Services. QUANTIFYING PATIENT EXPERIENCE AS PART OF THE VALUE EQUATION Hospital Consumer Assessment of Healthcare Providers and Systems The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) was the earliest comprehensive patient experience survey administered nationally by CMS. HCAHPS evaluates the in-hospital experience of medical, surgical, and obstetrical patients through patient feedback. It focuses on clinician care and communication, as well as on hospital cleanliness and quietness.4 In April 2015, CMS ranked hospitals by HCAHPS scores (http://www.medicare.gov/hospitalcompare/); only 251 institutions (7%) received top honors (5 stars). These CMS rankings were well publicized.5 The public reporting, financial implications, and explicit identification of care deficits by HCAHPS motivated hospitals to improve patient experience.6 Although 2 early studies did not find an association between HCAHPS scores and other surgical outcomes,7,8 both studies acknowledged that a surgery-specific instrument might better assess the relationship between patient experience and perioperative outcomes. Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey The American Society of Anesthesiologists and American College of Surgeons helped develop the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (Surgical CAHPS) as an analog to HCAHPS for the perioperative experience. Both organizations support its use as the patient experience metric for the Value-Based Payment modifier for surgical procedures and for public reporting on Physician Compare (www.medicare.gov/physiciancompare/).c Although there are numerous validated instruments assessing patient satisfaction with anesthesia care,9,10 we focus on Surgical CAHPS because it is administered by the Agency for Healthcare Research and Quality, and endorsed by the National Quality Forum (#1741). Surgical CAHPS is uniquely positioned to deploy nationally, to modify (i.e., incentivize or penalize) CMS reimbursements, and to influence hospital and departmental reputations. The current version of Surgical CAHPS (2.0)d has 47 questions: 26 actionable, 2 quantitative rankings, 10 demographic, and 9 filter questions to guide the respondent. Of the 47 questions, 8 are in the anesthesiology section (Table 1), and only 3 are actionable, all pertaining exclusively to the preanesthesia visit: Did this anesthesiologist encourage you to ask questions? Did this anesthesiologist answer your questions in a way that was easy to understand? Did talking with this anesthesiologist during this visit make you feel more calm and relaxed? Table 1: Anesthesiology Section of the CAHPS® Surgical Care SurveyThe final question is a quantitative ranking: Using any number from 0 to 10, where 0 is the worst anesthesiologist possible and 10 is the best anesthesiologist possible, what number would you use to rate this anesthesiologist? Figure 2: Perioperative patient experience. The perioperative patient experience can span months. Surgical CAHPS evaluates only the preanesthesia visit for anesthesiology’s contribution to patient care. Anesthesiologists are trained to manage patients and processes throughout the perioperative experience. It is imperative to the growth and development of our profession that the breadth of anesthesiologists’ contributions to perioperative patient care and experience are understood by patients and clinicians and assessed by valid outcome metrics. The linear symbols above the locations at the bottom of the figure symbolically represent a timeline: □ identifies a new location, --/ /-- identifies a varying amount of time at the location (from hours to weeks depending on the clinical scenario), and the numbers in circles are associated with the prototypical interactions a patient has with his operating room anesthesiologist. PACU = postanesthesia care unit; POD#0 = day of operation; SCAHPS (Surgical CAHPS) = Consumer Assessment of Health Care Providers and Systems Surgical Care Survey; SICU = surgical intensive care unit.The anesthesiology section of the Surgical CAHPS asks 3 questions about the preanesthesia visit and requires an ordinal ranking of the anesthesiologist from worst to best. It neglects the majority of anesthesiologists’ perioperative contributions (Fig. 2). Surgical CAHPS devalues the impact of anesthesiologists on a patient’s perioperative experience by making only 3 of the 26 actionable Surgical CAHPS questions about anesthesiology, focusing only on a single anesthesiologist, and including none of the results in the scoring rubric.11 Beyond the Ether Screen: Anesthesiology and Patient Experience CMS states that patient experience metrics in the perioperative period are a priority. We agree but do not believe that the anesthesiology section of Surgical CAHPS is a valid tool to assess the value of anesthesiologists to the perioperative patient experience. Surgical CAHPS, like many patient experience surveys assessing an anesthesiologist’s care within a care team model, has issues with validity.12 First, patients often interact with multiple anesthesiologists during the perioperative time period. Even when the same anesthesiologist performs the preoperative visit, intraoperative anesthesia care, and postoperative visit, <15% of patients recognize the anesthesiologist’s name 6 weeks after surgery13 when Surgical CAHPS may be administered. Second, Surgical CAHPS focuses only on a single anesthesiologist: perioperative outcomes are a result of intradisciplinary and interdisciplinary collaboration, and ascribing accountability to an individual anesthesiologist is challenging14 and likely inappropriate.15 Finally, and partly related to benzodiazepine premedication, 60% of patients have some component of amnesia to events before induction of general anesthesia,16 the only period Surgical CAHPS evaluates. Future iterations of Surgical CAHPS must more accurately represent and assess anesthesiology’s impact on patient experience. Foremost, anesthesiology is a team-based specialty, and Surgical CAHPS should evaluate anesthesiologists as a team and anesthesiology as a system. In addition, anesthesiologists contribute to patient care at multiple critical moments in the perioperative period.17 The instrument should assess clinical and systems issues related to the preanesthesia clinic, operating room team, postanesthesia care unit, intensive care unit, and pain management team. Finally, the questions must be validated in the appropriate surgical populations.18 ANESTHESIOLOGY AS A COMPREHENSIVE PERIOPERATIVE CARE TEAM Anesthesiology must proactively address our value proposition challenge by projecting the complexity and impact of anesthesiology-provided perioperative care to our colleagues and our patients. The demonstration of anesthesiology’s value to the patient experience, which includes promoting patient engagement,19 sharing clinical decisions,20 and incorporating patient voices into performance improvement,21 should emphasize the nonoperative time of the perioperative experience.22 Organizationally Transforming Anesthesiology to Display Its Actual Value Anesthesiology can use this mandate for quality and patient experience metrics to motivate the transition of anesthesiology’s identity from fellowship-based departmental subspecialties to the perioperative surgical home (PSH) with an identity that emphasizes perioperative coordination of care. The PSH can function as an integrated practice unit displaying the breadth of involvement that anesthesiologists have in the perioperative period: preoperative medical assessment and optimization, interdisciplinary coordination, risk stratification, crisis management, knowledge of intraoperative physiology and pharmacology, and postoperative medical and pain management. The PSH,23 or Perioperative Enhancement Team, as entitled by Duke Anesthesiology, clearly demonstrates anesthesiologists’ role and value to the health care system. The PSH is a venue to longitudinally engage and advocate for patients from diagnosis to recovery. We can start this effort in the current model of anesthesia care by capitalizing on the perioperative experience as a teachable moment for patients.24 The preanesthesia clinic can provide a touchstone interaction between anesthesiologists and patients and may be a foundation for the PSH. However, for the subset of patients who do not attend the preanesthesia clinic, they have their initial contact with an anesthesiologist on the day of surgery with the preanesthesia visit. Anesthesiologists can provide a greater value to the patient experience and to the health of the population by expanding the traditional preanesthesia history and physical, risk stratifying patients, and developing customized, best practices. In addition, intraoperative physiologic and pharmacologic observations can be communicated postoperatively to intensive care and pain medicine colleagues to optimize management. The same information can be used to educate patients on their individual physiology and its implications for their long-term health. These efforts will better inform patients about their health and anesthesiologists’ roles in their health care and result in greater patient satisfaction.25 If we do not work toward these goals, we risk diminished relevance in a health care system that increasingly values publicly reported, patient-centered, patient feedback metrics.26 Operationalizing the Change Anesthesiology needs to clearly define anesthesiologists’ value proposition and broadcast it to patients, payers, and other clinicians.27 We must ensure Surgical CAHPS, and all metrics of anesthesiology quality, focus on the entirety of anesthesiologists’ perioperative contributions and thus assess the intended constructs and provide valid and actionable data. We have to continue to collect and analyze data from the entire perioperative period and change our practice with the results.28 Multicenter Perioperative Outcomes Group29 and National Anesthesia Clinical Outcomes Registry30 are foundational platforms to further develop and emulate. Because direct patient feedback cannot provide us with actionable intraoperative data,31 we should consider seeking feedback from our intraoperative colleagues: surgeons, nurses, allied professionals, and administrators to improve the quality of anesthesiology’s contribution to our patients’ experiences and outcomes. Anesthesiologists can best advocate for our patients when we function as a part of their perioperative clinical team. CONCLUSIONS Anesthesiologists have helped refine the intraoperative patient experience to its current level of safety and efficiency, and we continue to improve its effectiveness through standardization32 and reduction in complications33 and costs.34,35 With the mandate to evaluate anesthesiology’s contribution to patient experience, the metrics cannot be focused on the individual but must be on the care team. We must systematically display our value with anesthesiology-led, patient-centered, care coordination through the PSH as a key part of our future and be assessed accordingly. Our success with the intraoperative experience must now be expanded, by improving patient experience and patient value throughout the perioperative period.36 We should embrace this opportunity to prepare our profession for success and leadership in current and future health care paradigms. DISCLOSURES Name: Matthew J. Meyer, MD. Contribution: This author helped write the manuscript. Attestation: Matthew J. Meyer approved the final manuscript. Name: Joseph A. Hyder, MD, PhD. Contribution: This author helped write the manuscript. Attestation: Joseph A. Hyder approved the final manuscript. Name: Daniel J. Cole, MD. Contribution: This author helped write the manuscript. Attestation: Daniel J. Cole approved the final manuscript. Name: Nirav V. Kamdar, MD, MPP. Contribution: This author helped write the manuscript. Attestation: Nirav V. Kamdar approved the final manuscript. This manuscript was handled by: Franklin Dexter, MD, PhD. ACKNOWLEDGMENTS We thank Dr. Carl Rosow for his insightful critiques that strengthened our argument, Dr. Brian Bateman for his editing and support, and John William Meyer for his microeconomics review.