Open Your Mouth, Stick Out Your Tongue, and Say “Five”

by Carol A. Westbrook

6a00d8341c562c53ef01b8d1c5ba95970c“What should I do with this?” my husband asked, as he handed me the letter. It was a Press Ganey survey asking him to evaluate a recent visit to his doctor.

In case you have never seen one, a Press Ganey survey is a multi-page questionnaire in which you asked to rate your experiences during a hospital or outpatient clinic visit, from 0 (bad) to 5 (best). The completed questionnaire is mailed to Press Ganey, which compiles and analyzes the data, and reports the results to the hospital or health care system that ordered the survey.

The survey asks questions like, “Did you have to wait long to see your doctor? Was the staff pleasant? Was the waiting room clean? Did your doctor take enough time to explain things to you? Did your doctor smile and shake your hand? Did the valet parker return your car promptly?” It also does not ask questions that the health care organization does not want to hear, for example, “Was your doctor given enough time with you? Did you actually get to see the doctor instead of the nurse practitioner? “Press Ganey has been called an Angels' List for clinics and hospitals.

That is why administrators love Press Ganey surveys–because they know that good scores will bring in more business. They also have the side benefit of providing an outlet for unsatisfied or angry patients who otherwise would be pounding on their door. Giving a doctor a “0” makes a disgruntled customer feel that he is addressing a problem, without the manager ever having to do anything about it!

Most importantly, though, patient satisfaction scores provide “objective” data that can be used to manipulate physicians by lowering their salaries or even firing them if they do not maintain a high score.

Patients are frequently surprised to learn that the salaries of their doctors are tied to their survey scores, yet this is the reality for almost two-thirds of physicians employed by health care groups. For some doctors, 10% to 20% or more of their salary is at risk. Fortunately for me, when I was an employed physician it was only about 1%.

Why do administrators push physicians to drive up their patient satisfaction scores? For two simple reasons: higher scores bring in more business, but will also result in higher payments for their business, due to the “Pay for Performance” mandate.

To understand the “Pay for Performance” mandate, it helps to look at the history of the Press Ganey organization. The survey was created in 1985 when an anthropologist and a sociologist were asked to provide a tool for hospitals to determine if patients were satisfied with the care that they received. The business expanded rapidly after 2002, when CMS, the Federal agency that administers Medicare, announced a program to survey patients and require public reporting of the results. This was the result of a Federal a mandate to empower patients to make more informed decisions about health care by improving accountability and public disclosure. In 2003 Press Ganey went private for $100 million and was sold four years later for $673 million. Today, it typically reports over $200 million in yearly sales.

Press Ganey's business got another boost recently with the ObamaCare “Pay for Performance” initiative. Hospitals that perform poorly on quality measures forfeit 1% of their Medicare payments, a number that will double in 2017, putting some $2 billion at risk. Thirty percent of that determination will be based on hospital rankings from mandated patient surveys. Because so much is at stake, administrators push their physicians to generate higher scores. A Press Ganey survey for a large health care system such as the Cleveland Clinic could easily cost a half million dollars. Who pays for this? You, the patient. It is yet one more reason that a night in a hospital room costs more than a stay in a luxury New York hotel.

Yet it is hard to imagine that Press Ganey truly addresses the “pay for performance” mandate. A patient survey is not capable of measuring doctors' competence or performance. What they measure, instead, is patient satisfaction with their visit to the doctor. And there is a serious downside to coercing a physician to accede to their patients' desires, since those desires may be medically inappropriate or even harmful.

A recent study published by researchers at UC Davis (1), using data from nearly 52,000 adults, found that the most “satisfied” patients spent 9% more on health care and prescription drugs, were more likely to be admitted to hospital, and had higher death rates. It has been speculated that these patients were more satisfied because they were given what they requested–including extra tests and medications, which may lead to more harm or complications. Dr. Aleksandra Zgierska, an addiction specialist, believes that the epidemic rise in narcotic addiction is partly due to physicians' over-prescribing pain medication in order to improve their patient satisfaction scores. In an article for the Journal of the American Medical Association in 2012 (2) she wrote, “Patients can report dissatisfaction based on real or perceived problems including whether a clinician did or did not prescribe a desired medication. In some institutions, the first question on the patient satisfaction survey queries the extent of agreement with the statement: 'I was satisfied with the way my doctor treated my pain.'”

Pressures on physicians to drive up patient satisfaction scores to provide better care may thus have the opposite effect of leading to worse care, while further driving up costs. In my opinion it would make more sense if the hospital administrators–who control scheduling, cleanliness, and ambiance–had their salaries tied to Press Ganey scores, and let the physicians establish their own performance measures. There are a number of professional organizations that provide this service, such as The Joint Commission on Accreditation of Healthcare Organizations, whose surveys have led to improvements such as decreases in hospital-acquired infections, fewer falls, and fewer unnecessary blood transfusions. But Joint Commission surveys are performed by health care professionals rather than patients, while Press Ganey surveys are performed by a multi-million dollar company with great lobbying power. Perhaps it is time to rethink the “Pay for Performance” mandate.

“What should I do with this survey?” my husband repeated. Pix exam

I was inclined to tell him to throw it in the trash, given my dislike of patient satisfaction surveys. But then I had another thought.

“Answer every question with a 5,” I suggested.

“But it's a survey. I can't give all fives!” he protested. Like many adults raised in our school system, he couldn't give all 5's any more than he could answer all his SAT questions with the same letter answer. Or could he?

“Why not?” I asked, “You like your doctor, and there was nothing negative about your experience.”

He did as I suggested.

If we patients took a stand and agreed to score every survey item with a “5,” then the patient satisfaction survey, and its unnecessary added costs, would become meaningless. With luck, it would be replaced by a system that truly measures a doctor's competence and performance, rather than office ambiance. This is unlikely to happen, but I can dream, can't I?


1. Joshua J. Fenton et al. A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. 2012;172(5):405-411

2. A. Zgierska et al. Patient Satisfaction, Prescription Drug Abuse, and Potential Unintended Consequences. JAMA 2012 Apr 4: 307(13) 1377-1378