With Medicare Pay On The Line, Hospitals Push Harder ToPlease Patients

Carl Denham was hospitalized at Rowan Regional Medical Center in North Carolina in December.Denham, seen with his daughter Benicia, said his second visit to the hospital was much better thanhis first one two years before. Jordan Rau/Kaiser Health News hide caption

itoggle caption Jordan Rau/Kaiser Health News

Carl Denham was hospitalized at Rowan Regional Medical Center in North Carolina in December.Denham, seen with his daughter Benicia, said his second visit to the hospital was much better thanhis first one two years before.

Jordan Rau/Kaiser Health News

Lillie Robinson came to Rowan Medical Center for surgery on her left foot. She expected to be in andout in a day, returning weeks later to the Salisbury, N.C., hospital for her surgeon to operate on theother foot.

But that's not how things turned out. "When I got here I found out he was doing both," she said. "Wedidn't realize that until they started medicating me for the procedure." Robinson signed a consentform and the operation went fine, but she was in the hospital far longer than she'd expected to be.

"I wasn't prepared for that," she said.

Disappointed patients such as Robinson are a persistent problem for Rowan, a hospital with some ofthe lowest levels of patient satisfaction in the country. In surveys sent to patients after they leave,Rowan's patients are less likely than those at most hospitals to say that they always received helppromptly and that their pain was controlled well. Rowan's patients say they would recommend thehospital far less often than patients elsewhere.

Feedback from patients like Robinson matters to Rowan and to hospitals across the country. SinceMedicare began requiring hospitals to collect information about patient satisfaction and report it tothe government in 2007, these patient surveys have grown in influence. For the past three years, thefederal government has considered survey results when setting pay levels for hospitals. Someprivate insurers do as well.

In April, the government will begin boiling down patient feedback into a five-star rating. Federalofficials say they hope that will make it easier for consumers to digest the information now availableon Medicare's Hospital Compare website. The hospital industry says judging a hospital on a one-t--five scale is too simplistic.

Nationally, hospitals have improved in all the areas the surveys track, including how clean and quiettheir rooms are and how well doctors and nurses communicate . But hundreds of hospitals have notmade headway in boosting their ratings, federal records show.

"For the most part, the organizations that are doing really wonderfully now were doing well five

years ago," said Deirdre Mylod, an executive for Press Ganey, a company that conducts the surveysfor many hospitals. "The high performers tend to continue to be the high performers and the lowperformers tend to be low performers."

Some hospitals have made great gains. The University of Missouri Health System created a livesimulation center at its medical school in Columbia to help doctors learn to communicate better withpatients. The simulations use paid actors. Instead of having to diagnose the patient, doctors mustrespond to nonmedical issues, such as a feuding teenager and mother or a patient angry that he wasnot given information about his condition quickly enough.

"My scenario was I was late to the appointment and the patient's husband was upset," said KristinHahn-Cover, a physician at Missouri's University Hospital. In 2013, the most recent year that thegovernment has provided data for, 78 percent of patients at University Hospital said doctors alwayscommunicated well, a 10 percentage-point jump from 2007. Other scores rose even more.

Nudging up scores has been a frustrating endeavor elsewhere, such as at Novant Health, a nonprofithospital system that runs Rowan Medical Center and 13 other hospitals in North Carolina, SouthCarolina and Virginia. While some Novant hospitals have excellent patient reviews, Rowan's scoreshave remained stubbornly low since Novant took over the hospital in 2008.

Last fall, Rowan's president, Dari Caldwell, replaced the physician group that ran the emergencyroom because the doctors had not reduced wait times. ER waits are down to half an hour, aspokeswoman said. Doctors and nurses also are being coached on their bedside manner, like beingadvised not to stare at their computer when a patient is talking.

Rowan's nurses now spend 70 percent of their time with patients, swinging by every hour. Even thepresident makes rounds once a day. The hospital has made lots of small improvements to provide awarmer environment, such as putting white poster boards in each room where nurses can list a fewpersonal details about their patients.

"I can go in there and say 'Oh, you have three dogs' or 'You have a grandchild, that's great, great,'"said Jennifer Payne, a nurse manager. "And they can talk for hours about that."

Patient perceptions have been tough to change at Rowan Regional Medical Center in Salisbury, N.C.Joanna Serah/Wikimedia hide caption

itoggle caption Joanna Serah/Wikimedia

Patient perceptions have been tough to change at Rowan Regional Medical Center in Salisbury, N.C.

Joanna Serah/Wikimedia

Payne said she pores over patient comments and surveys, passing around the good ones and tacklingcomplaints. "We're very driven by what these patients say," she said. "Everything I do is basedaround how these patients come back [in comments in the surveys] and say, 'Hey, is this working?'or 'This isn't working.'"

Rowan executives fear scores may not be going up because patients still harbor bad memories fromprevious hospitalizations.

"I was treated like a dog," Carl Denham, 76, said about a stay two years ago. He said the hospital

was doing loud construction work that kept him awake, and it took nurses all day to deliver anoxygen tank his doctor ordered.

Admitted again in Rowan in December, Denham said that visit was different. "It is fantastic fromwhat it used to be if you want my opinion," he said as he lay in his hospital bed a few days after hecame back. "I've been both ways and the way it is now, it is great. No waiting and the doctors are allpleasant. I never thought I'd see it like this." He said he would give the hospital top marks.

His daughter Benicia said that in the last visit she had to nag the nurses to get her dad hismedication. This time, it has not been an issue. "It's like a totally different hospital," she said. "I hadto say, 'Did I come to Rowan Regional?'"

Despite the unexpected operation on both feet, Robinson also said nurses have been attentive to herpain. "They do the best they can," she said. "At times it gets so bad I'm crying because it'soverwhelming to me."

But "the best they can" is not good enough for Medicare. In determining how much to pay hospitals,the government only gives credit when patients says they "always" got the care they wanted duringtheir stay, such as their pain was "always" well-controlled. If a patient says that level of care was"usually" provided, it does not count at all. Likewise, the surveys ask patients to rank their stays on ascale of 0 to 10; Medicare only pays attention to how many patients award the hospital a 9 or 10.

"Sometimes what we see and hear from our patients doesn't show up on their surveys," Caldwellsaid.

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