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  • Writer's pictureDr. Errol Norwitz, MD, PhD, MBA

U.S. Healthcare: Tracking the satisfaction of the end-user, the patient

Updated: Apr 29

This blog is part three of a six-blog series on "US Healthcare: A Bureaucratic Quagmire Needing Disruption". If you haven't read the first two blogs yet, please read them from the link provided at the end of this blog.


At its core, healthcare is about patients. Advances in healthcare, however, are too often driven by the interests of the researcher, academic institution, or company, resulting in a mismatch in priorities between researchers, clinicians, and patients. One such example is a preoccupation with studying drug treatments rather than education and nondrug therapies that patients and clinicians prefer as treatment options.[1,2] Another is the increased utilization of interventions in the last year of life, which consumes around 10% of the U.S. healthcare budget. Patients don’t necessarily want complicated, expensive treatments that are unlikely to impact the length or quality of their lives, and yet providers often have a difficult time choosing to do less. We need to promote ‘evidence-informed hope’—not because it saves money, but because it respects the dignity of the individual and reinforces their right to make informed decisions around their end-of-life care.


Given that healthcare exists to serve the patient, the patient’s opinion based upon their experience and outcome is paramount. When asked, patients prioritize four elements for their care: they want it to be accessible, affordable, compassionate, and high-quality.


Accessible Care 

Accessible care requires both coverage (health insurance) and access. Although distinct, they are closely connected. Coverage makes it easier to get access but does not guarantee it. Access refers to the ability to see the right provider at the right place and right time. This need not be (and often should not be) an in-person visit with a physician—it could be a telemedicine consult or a visit with a nurse or physician’s assistant. Passage of the Affordable Care Act (ACA) in 2010 and subsequent legislation in 2014 that enabled states to expand Medicaid eligibility and establish health insurance marketplaces dramatically decreased the uninsured rate in the U.S. from an average of 15% the decade prior down to a low of 7.9% in 2022—from 44 million uninsured Americans in 2013 to around 26 million in 2022.[3] Access, however, remains a challenge with more providers leaving the workforce and, as yet, too little ‘task-shifting’ to alternative providers.


Percentage of Americans without health insurance
Image Source: Peter G. Peterson Foundation


Affordable Care

Affordable care is a particular challenge in the U.S. given the high cost and lack of a comprehensive national safety-net program. The COVID-19 pandemic heightened awareness of health insurance's value, even among the so-called ‘invincibles’ in their 20s and 30s. People in the U.S. who are uninsured are so not because they don’t want health insurance but because they can’t afford it. And having a job doesn’t guarantee coverage—about half of small businesses in the U.S. don’t offer health insurance, and three-quarters of the uninsured have at least one full-time worker in their family.[4] What constitutes affordable care? Most people consider 2-5% of income to be affordable for out-of-pocket health insurance costs (including premiums, deductibles, and co-pays).[4] In 2020, out-of-pocket healthcare costs in the U.S. were estimated at 18.7% of average household income (or $9,393 per person),[5] well out of reach of most Americans.


Compassionate care

Compassionate care—the ability to engage emotionally and deliver care based on empathy, respect, and dignity—is an important part of how patients' perceive their care. When healthcare professionals engage in compassionate communication, they listen attentively, speak with kindness, and validate the patient’s feelings. The goal is to leave a patient feeling heard, respected, and cared for—not just as a clinical case but as a person. For many patients and families, compassionate care is seen as a proxy for high-quality care, which it is not. However, a compassionate culture does enhance staff well-being and reduce stress, absenteeism, and medical errors, leading to improved patient outcomes.

"Empathy has no script. There is no right way or wrong way to do it. It is simply listening, holding space, withholding judgement, emotionally connecting, and communicating that incredibly healing message of ‘You’re not alone.’”
-- Brené Brown --

High-Quality Care

High-quality care is typically mentioned last by patients when asked what they are looking for in a healthcare system. This is because most Americans simply assume that their physician and their care are good. They don’t take the time to research their providers, despite a wealth of reliable online data, choosing instead to rely on brand or a word-of-mouth recommendation or scheduling convenience. However, not all healthcare providers and healthcare systems are created equal. There is tremendous variation across the country in how patients are treated for the same condition, with only half of physicians adhering to national practice guidelines.[4] 


The Institute of Medicine in the U.S. has presented a clear definition of what constitutes high-quality healthcare and includes 6 elements: safe, effective, patient-centered, timely, efficient, and equitable.[6] Unfortunately, U.S. healthcare falls short in many aspects. Medical errors account for over 250,000 deaths annually in the U.S.—comparable to a fully loaded, double-decker Airbus A380 airplane crashing every day of the yearmaking medical errors the third leading cause of death.[7] Patients need to become more literate about what constitutes high-quality care and more discerning in choosing their care provider—it is not simply the ability to get a timely appointment and their perception that their provider is listening to them.


Given that the patient’s perception is paramount, how can this be measured? The most widely used metric is the Net Promoter Score (NPS®). Developed in 2003 by Fred Reichheld, a partner at Bain & Company in Boston,[8] it measures how well an organization treats the people whose lives it affects. It provides an overall score of customer satisfaction and loyalty built around a single survey question based on the customers’ perception on a rating scale of 1-10: “How likely is it that you would recommend [this provider or this organization] to a friend or colleague?” A composite score is then calculated by % promoters (scores 9 and 10) minus % detractors (scores 0-6). Although absolute scores vary by industry and region, comparing scores across similar-sized institutions within the same industry provides a reliable benchmark against which to compare an organization’s customer satisfaction. When repeated at regular intervals, it can be used to compare and track an organization’s progress over time.


Net Promoter Score

A favorable NPS® correlates not only with customer satisfaction and loyalty but with future growth and financial success. Do you know your institution’s NPS®—not the percentile, which is misleading, but the actual numerical score? Did you know that the average score for U.S. hospitals in 2023 was +58? [9] How does your institution compare? You may be surprised.


Note: If you haven't read the previous parts of this blog series, we recommend you to read it from our official website: US Healthcare: Misaligned Incentives, Why is US Healthcare so expensive? and US Healthcare: Lack of Engagment

Authors: This Blog is Co-authored by Dr. Errol Norwtiz and Venkata N. Peri


References:
  1. Tallon D, Chard J, Dieppe P. Relation between agendas of the research community and the research consumer. Lancet 2000; 355:2037-40.

  2. Chalmers I, Atkinson P, Fenton M, Firkins L, Crowe S, Cowan K. Tackling treatment uncertainties together: the evolution of the James Lind Initiative, 2003–2013. J R Soc Med 2013; 106:482-91.

  3. www.pgpf.org/blog/2023/11/the-share-of-americans-without-health-insurance-in-2022-matched-a-record-low

  4. Garson A, Holeywell R. Exposing the 20 Medical Myths: Why everything you know about health care is wrong and how to make It right. 2022 update. Rowman & Littlefield Publishers, London. 2019.

  5. www.rand.org/news/press/2020/01/27.html

  6. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press; 2001.

  7. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ 2016; 353:i2139.

  8. https://customergauge.com/benchmarks/blog/nps-healthcare-net-promoter-score-benchmarks

  9. www.netpromotersystem.com/about


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