Patient Experience in the Medicare Population: Follow the Money or the Patients?

^{The outpatient setting could be ripe for an improved patient experience.}

Most of the initiatives to improve the patient experience have focused on hospitalizations and interactions between doctors and patients in the hospital setting. Healthcare organizations don’t focus sufficient attention on the outpatient setting and therefore could be missing an important opportunity to favorably influence patient experience.

The basic facts about Medicare are well known: In 2018, Medicare spending was about $3.3 trillion, or about 18 percent of the U.S. GDP. Medicare covers 15 percent of the U.S. population, about 44 million beneficiaries, and that number is expected to increase to 79 million by 2030.

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The largest cost center for Medicare spending is the hospital setting; in-patient costs total roughly $133 billion. What is not as well appreciated is that these hospital costs are incurred by only 7.7 million beneficiaries, which is only 17 percent of the Medicare population.

Now examine the stark differences from the outpatient setting. For outpatient activities, the Medicare spend was $68 billion, or about half of the hospital spend. But these activities involved 34.2 million beneficiaries (about 77 percent of the Medicare population), clearly indicating that more Medicare patients have outpatient medical encounters compared to hospitalizations.

On the one hand, focusing patient experience activities on hospitalizations makes sense because that is where the greatest amount of Medicare money is spent. But on the flip side, the outpatient setting is where most Medicare patients live.

There is a second reason to think about focusing more attention on the outpatient setting: It’s where you have a better chance to make a real difference in the perception of the patient experience.

Think about patients in the hospital — they are sick, frightened and uncertain about the future. Moreover, they are completely out of their comfort zone; they are not sleeping in their own beds, they are eating unfamiliar foods and they are likely operating on a totally different schedule than the one they’d follow at home. My own experience from more than 35 years of clinical practice is that patients in the hospital setting are really listening for the answers to only two questions: 1) Am I going to die?; and 2) When can I go home? Being in the hospital is inherently an adverse experience — we just want to mitigate the unpleasantness as much as possible.

On the other hand, outpatient encounters are vastly different. These encounters are much shorter, and there is limitation in scope. Patients are still living their lives and so their expectations about schedules, meals and the like are vastly different from those of the hospitalized patient. Yes, in some cases, an outpatient visit can be viewed as a retail transaction — and this would never be the case in a hospital setting. In my experience, the outpatient setting is much more conducive to teaching, setting goals and making patients feel important. My own clinic has implemented a program in which we see patients within three to five days of discharge from the hospital. Just last week, a patient said to me, “Now I finally understand what everyone is talking about!”

Improving the patient experience in the hospital setting is an important and valuable goal. However, the outpatient setting is much more fertile environment for the types of activities that are likely to help improve patient satisfaction.

One final distinction between the inpatient and outpatient experience: It is difficult to find a common theme that will be relevant to all the different types of patients who receive care in a hospital. What is important to a patient admitted electively for a hip replacement is light years away from a patient admitted with sepsis following chemotherapy. What is important to the pediatric patients is very different from patients recovering from coronary bypass surgery. So, the patient experience “platform” will necessarily be different between different floors of the same hospital. But one can imagine that it is far easier to produce a common platform to improve the outpatient experience compared to improving the inpatient experience. To maximize health and experience impact, we need to look at improvement there.

Several groups and health systems have taken calibrated steps to help improve the outpatient experience in primary care practices. One example is a fully compliant digital communication platform that helps to improve outcomes with reminders to schedule tests and congratulatory messages on completion of the preventative measures. Supplementing this technological connection is the use of nursing assistants and community health workers who can add the personal touch that is so important to make the delivery of healthcare a comforting event.

It is abundantly clear that patients appreciate the enhanced communication, the encouragement and the personal touch — and that these improvements yield the motivation required to become a more active participant in their own healthcare.

Spencer H. Kubo, M.D., is chief medical officer of CareCognitics.

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