Hayward D, de Riese W and de Riese C: Potential bias of patient payer category on CG-CAHPS scores and its impact on physician reimbursement. Urol Pract 2021; 8: 454.

When the Medicare Access and CHIP Reauthorization Act (MACRA) was passed in 2015, physician reimbursement from the Centers for Medicare and Medicaid Services (CMS) went through a paradigm shift. The legislation transitioned reimbursement from fee-for-service to fee-for-performance, using the new Merit Based Incentive Payments System (MIPS). One of the available quality measures included in MIPS is patient experience obtained by qualified surveys (such as Press Ganey® [PG]). The quantified survey results submitted by patients grade their physicians’ services. Some major commercial insurance companies have followed the lead of CMS by switching to value-based reimbursement. It is likely that all payers will eventually utilize a value-based reimbursement algorithm. Therefore, patient satisfaction has become an important payment modifier. However, these models should provide a true reflection of physician performance and adjust for potential skewing factors in non-modifiable patient demographics, which cannot be controlled by physicians.

In this context we investigated potential patient bias in survey scores associated with payer type in an academic urology outpatient clinic setting. This was a cross-sectional, retrospective study investigating self-reported, de-identified patient satisfaction surveys completed in the urology clinic at Texas Tech University Health Sciences Center (TTUHSC). The PG surveys (with a 0-100 grading score) were sent either electronically or on paper. All patients with an email address received an electronic PG survey for each clinical encounter. Paper surveys were sent to 1 out of 5 patient encounters via random selection. The survey results of more than 20,000 patients of this academic urology clinic were analyzed and stratified by the following major payer categories: commercial insurance, Medicare, Medicaid, other government plans, Workers’ Compensation, and self-pay/uncompensated. Patients covered by Medicare, commercial insurance, and other government coverage (such as Tricare) showed the highest satisfaction scores in comparison to Workers’ Compensation, Medicaid, and self-pay/uncompensated (see table). These differences were statistically significant, and are consistent with findings from previous studies in non-urology services.^1-4 Medicare returned the highest patient experience scores, followed closely by other government coverage and private insurance. Medicaid and self-pay were similar in returning the lowest scores confirming correlation between non-modifiable patients’ attributes and satisfaction scores. In this context it is noteworthy that some studies also showed lack of association between high patient satisfaction ratings and improved outcomes.^5,6

There are limitations in these studies, such as low return rates on completed surveys and disparity between email surveys and paper surveys, potentially excluding many patients without email access. Remarkably low response rates of patients to any survey instruments have been reported.^7,8 With recorded response rates between 3% and 16%, it is doubtful that the documented evaluations of a physician are entirely representative of the physician’s quality performance. Inherent selection bias and non-response bias potentially skew any analysis. Furthermore, these studies investigated a limited population, and results may vary between regions (eg rural versus urban) or between different types of practice within the same specialty. Future studies should also focus on how patients’ demographics such as age, gender, education, and ethnicity are affecting patient satisfaction scores.

The low scores by Medicaid patients are consistent with previous studies.^3,9 A study done by Liu et al found that hospitals with a higher proportion of Medicaid patients received lower patient satisfaction scores.¹⁰ Medicaid often covers the most vulnerable and disadvantaged patients. Future research should explore the driving factors of lower Medicaid patient satisfaction, which may include limited access to health care providers or medications. Physicians and hospitals that provide care for these individuals should not be inadvertently penalized for their work. Apparently the current system disincentivizes clinicians from caring for Medicaid patients.

Self-pay patients reported the lowest satisfaction scores. This may be due, in part, to the expensive nature of health care, and may reflect the financial burden of obtaining care rather than the physician’s quality of care. In this context it is important to note that studies in outpatient clinics have also demonstrated a lack of association between high patient satisfaction ratings and improved clinical outcomes.^5,6

The data available strongly suggest that patient experience scores are impacted by the type of insurance coverage and not only by the quality of care provided. Urologists should be aware of these nuances when selecting MIPS quality reporting metrics. Currently, these biased scores may have an impact on physicians’ reimbursement, and therefore policymakers should consider modifying reimbursement according to payer-mix.