The Patient Protection and Affordable Care Act (PPACA) of 2010 initiated the Hospital Value-Based Purchasing Program, which aims to reward quality rather than quantity of health care provided. Patient experience in hospitals is one such measure of quality. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a survey designed to provide a nationally standardized indicator of patients’ hospital experiences. Since its inception in 2008, the use of HCAHPS as an indicator of hospital performance has moved from optional to mandatory participation. As of fiscal year 2013, the Centers for Medicare & Medicaid Services
(CMS) is linking 1-2 percent of CMS funds for each hospital over the next five years to how well hospitals perform on the HCAHPS; this equals almost $1 billion in total payments. In 2013, 1 percent of each hospital’s Medicare payments were initially reduced and then, based on the quality of care provided by the hospital, a portion of that 1 percent could be recovered as a bonus. Some hospitals did not recoup any of these payments and were thereby penalized.1
HCAHPS is a set of 27 questions related to patients’ experience in the hospital administered at discharge to patients over 18 years old. Major response categories include:
• Communication with health care providers
• Responsiveness of hospital staff
• Cleanliness and quietness of the hospital environment
• Pain management.
Specific questions concerning pain include:
1. Did you need medicine for pain?
2. How often was your pain well controlled?
3. How often did the hospital staff do everything they could to help you with your pain?
At first glance, this seems a reasonable assessment of the patient experience. However, limitations are quickly apparent when one recognizes that some of the most challenging patients treated in hospitals today are those who are opioid-tolerant at admission. The FDA defines opioid-tolerant as patients taking 60 mg of morphine equivalence for seven days or longer. A recent review of data at the Massachusetts General Hospital has revealed that more than 10 percent of admissions per year would meet the definition of opioid tolerance.
The survey does not account for baseline lack of satisfaction in these opioid-tolerant chronic pain patients who may feel their pain was not adequately controlled even at home, much less when admitted for acute issues to the hospital. Providing optimal pain management to this population while minimizing maladaptive behaviors may not necessarily correlate with higher patient satisfaction in an acute setting such as hospitals. Patients with addiction issues present similar challenges. Patients who are addicted may never feel they have been given enough pain medication and might consistently give low satisfaction scores. In managing pain, then, hospitals are challenged to balance appropriate clinical care with patient satisfaction and the impact of this on HCAHPS scores.
An approach to balancing optimal pain management with patient satisfaction requires expectation management, clear algorithms of care and the early involvement of expert resources such as pain services. The keys may be as simple as communication, courtesy and empathy. Patient satisfaction has been strongly correlated with the perception that health care providers have done everything possible to control pain rather than with actual pain control.2 The preoperative clinic is an ideal place to intervene in terms of managing patient expectations and developing rapport. Patients with chronic pain who are opioid-tolerant may need more comprehensive strategies to manage their pain, from the use of perioperative regional anesthesia to bedside complementary therapies such as relaxation, acupressure, acupuncture, massage and TENS. Emotional support and spiritual counseling could be just as important as medication management. These strategies should be discussed with patients prior to their procedure.
Education of caregivers at every phase of hospital care on the need for early intervention with available expert resources, such as dedicated pain services, for this patient population may also help to reduce length of stay and readmission rates and improve overall patient satisfaction.
The need to incorporate pain management across the medical and surgical home models is critical; for a certain subset of patients, the concept of a “pain home” may be appropriate. The concept of a medical or surgical home model emphasizes quality and safety, coordination of care, a personal physician who directs medical practice, whole-person treatment, and improved access to care. In relation to the “pain home,” the concept can be developed by identifying patients at risk of poor pain outcomes, such as the opioid-tolerant or addicted, and creation of algorithms of care with clear pathways from pre-admission to post-discharge. Physicians, particularly anesthesiologists, must be at the forefront of constructing the pain home for this challenging population. We are ideally placed to take a leadership role in improving HCAHPS measures and shaping the management of acute and chronic pain in the evolving health care landscape.
Anna Woodbury, M.D. is a Pain Medicine Fellow, Emory University, Atlanta.
Kayode Williams, M.B., B.S. is an Assistant Professor, Johns Hopkins School of Medicine, Johns Hopkins Carey Business School, Baltimore.
Padma Gulur, M.B., B.S. is Director of Pain Services, Massachusetts General Hospital, and Assistant Professor, Harvard Medical School, Massachusetts General Hospital and Harvard Medical School, Boston.
1. Centers for Medicare & Medicaid Services. Medicare program; Hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2013 rates; Hospitals’ resident caps for graduate medical education payment purposes; Quality reporting requirements for specific providers and for ambulatory surgical centers; Proposed rule. Federal Register. 2012;77(92):27870-28192.
2. Hanna MN, González-Fernández M, Barrett AD, Williams KA, Pronovost P. Does patient perception of pain control affect patient satisfaction across surgical units in a tertiary teaching hospital? Am J Med Qual. 2012;27(5):1-6.