How Patient Satisfaction Surveys Contribute to the Opioid Crisis

By Dorri Olds 01/02/17

Doctor incomes are based on survey scores, and patients often give low scores if they don't leave with the prescription they want.

A hand filling out a patient survey, marking the "excellent" checkbox.
Where it all started?

The blame for our nation’s opioid epidemic is often placed squarely at the feet of doctors and their generous prescribing practices. That seemed the most likely explanation—until I spoke with ER doctor of osteopathic medicine Gerald O’Malley, DO. With 25 years of experience, the man is knowledgeable and surprisingly forthcoming about what goes on behind the scenes in hospital emergency rooms.

The biggest culprit in the opioid crisis, according to O’Malley, was the invention of the patient satisfaction survey and especially the decision to add questions about pain and pain management. These hospital surveys are mandated by the Centers for Medicare and Medicaid Services (CMS), the government organization that dictates payment for medical services and sets the agenda for the entire insurance industry.

“They made a mistake,” said O’Malley. “They conflated quality with customer satisfaction. If you feel satisfied, that does not mean you’ve received high quality healthcare.”

These surveys fly in the face of what the doctor-patient relationship should be built on: honesty. They’ve transformed the sick into consumers who rate their level of satisfaction with their purchase or service. The physician is no longer an advisor, he/she has become a corporate spokesperson—a merchant selling something. Hospital administrators hand out scripts to memorize and recite.

"We were told to say, 'Hi, my name is So and So, and I’ll be your doctor today,' and 'Please let me know if there’s anything we can do to make your experience here more pleasant.' It was incredibly insulting to me, and what you’d expect from a waiter or electronics salesman," said O’Malley. "I like to treat people as individuals, not somebody who came to the ER to spend money."

At Albert Einstein Medical Center in Philadelphia, O’Malley described a common scene where staff was summoned and given a stern talking to by a department chairperson; they were told they’d be judged by their survey scores.

“Then, just to be dramatic, I guess, the chair quoted a line from The Godfather," said O’Malley. “He said, ‘This is the business we’ve chosen.’ Which meant, if you don’t like it, get out.”

Incomes became based on survey scores. The hospital hired consultants to train them in order to get their numbers up.

“It had nothing to do with medical care,” said O’Malley.

Staff was told how to enter a room, knock on the door, and introduce themselves to everyone in the room. “We had to allow as many people into the room if they requested it. One time there were five family members; two in wheelchairs. There was literally no way for me to get to the bed. I had to play traffic cop and say, ‘I’m sorry, I understand you all want to be here but I need to perform an exam so some of you have to leave.’

“That kind of honest, blunt conversation was frowned upon by the administration. They don’t practice medicine so they don’t understand that it’s fucking impossible to try to talk to someone about anything sensitive. They may not want their family members to know what drugs they’ve taken. But asking everybody to leave is uncomfortable.”

Medical personnel are told to sit down during consultations. “Studies showed that sitting down fools patients into thinking you’re with them longer than if you stand while talking.”

I pointed out how manipulative that sounded. “You’re 100% correct,” he said. “All these things are done to manipulate the client into thinking they’re getting good care.”

Moods matter too. ER workers put in long hours and it’s easy to understand how their exhaustion could affect a satisfaction score. More importantly, anyone admitted to an ER is not feeling well. That person will be irritable, upset, scared. They might have been cold in the waiting room or had to wait too long. Nobody enjoys going to an ER and it is impossible to know how much to factor in when administrators review scores.

And what about drug abusers seeking narcotics? Surely, their opinion of a doc will be directly related to whether they get to leave with a prescription.

“When I worked at Albert Einstein Medical Center in North Philadelphia, folks came back time and time again—for back pain, headaches, sickle cell pain. They’d walk in and say, ‘I need two milligrams of Dilaudid 4 with 25 milligrams of Phenergan,’ and, ‘Come on, chop, chop, let’s go. Snap to it.’ Or they’d say, ‘I’m going home now, so I need a prescription for 50 tablets of oxycodone.’ After looking up their records in the computer, I’d have to say, ‘Hang on, you just got a prescription for 50 tablets of oxycodone last week.’

“Then suddenly, you’re in a confrontation. The patient is yelling ‘I want to speak to your boss!’ If it’s 2:30 in the morning, I was the most senior person there. In those circumstances I knew this was somebody abusing oxycodone or selling it in a school playground somewhere. So then it’s ‘What do I do now?’ Did I really want to deal with this for the next two weeks, having to explain why this guy got so pissed off and gave me bad survey numbers?”

It becomes easy to see why many docs choose the easier way—they just prescribe the requested meds. Emergency visits are skyrocketing because people cannot afford healthcare. They have nowhere else to go, and ERs are convenient because they're open 24 hours.

“I had a guy show up at three in the morning with a herpes outbreak. He said, ‘I need Acyclovir and Zovirax cream.’ Okay, that made sense. But then he said, ‘I need something for the pain—Percocet or Vicodin or Dilaudid.’ I go, ‘Dude, you’ve got herpes. It’s not like a broken leg.’

“He started yelling, 'I paid a $200 copay so give me my six-month prescription.' When I say no, then I’m the bad guy. He complains to the administration, then they come to me and say, ‘Why didn’t you just give him the prescription?’"

A major roadblock for hospitals is that they have to report the survey scores to the Centers for Medicare and Medicaid Services. “Look,” said O’Malley, “we have certain metrics we have to meet. If CMS doesn’t like our scores, then, guess what? They’re not going to reimburse us. We’re going to be out money.”

When a chronic pain sufferer comes into the ER at midnight and says they ran out of painkillers and need a prescription for an opioid, O’Malley said that puts him in a terrible position.

“I’ve never seen them before. I don’t know if the stuff they’re saying is true. I don’t want to see people in pain but I have a social responsibility not to contribute to this opioid epidemic. They say, ‘I don’t care about your social responsibility. I want my narcotics NOW! If I don’t get them I’m going to slam you on your evaluation.’"

We moved onto the topic of administering Narcan (naloxone). “After you revive someone, they often get pissed off and start screaming at you. They jump off the bed, and run out of the ER. That is terrifying. Narcan is only going to last 20 to 30 minutes. If they overdosed on opioids like methadone or oxycodone they’re going to go back into respiratory arrest, or pass out at the top of a staircase, or get behind the wheel of a car.”

O’Malley sees the increased availability of Narcan as a positive. “I know there’s a lot of people who say it’s contributing to drug abuse. Well, yeah, maybe, but it also saves lives. As an emergency medicine professional, you tend to be the eternal optimist. You think, ‘This person was rescued from an opioid overdose 12 times already but maybe the 13th time, they will get into a Suboxone treatment program. They’ll get off the drugs and finally get their life together.’ Maybe it’ll be the 16th time. You have to believe your efforts are not in vain. These efforts have meaning, because no matter who they are, their life has meaning. Maybe it’ll be the 26th time before they’re able to turn themselves around and redeem their life.”

I asked if he was always too busy in the ER to follow up and suggest a recovery program, like Narcotics Anonymous or Alcoholics Anonymous, or a rehab, or SMART Recovery. He makes the time.

“I’ll always wonder how they got so broken that they ended up in my ER after a near-death experience. I talk to them probably more than most. I’m interested in their stories. I want to know what happened to them. Many don’t feel like sharing. They say, 'Go fuck yourself,' and storm out. They don’t want to listen to me, but I have had some meaningful conversations. I learn they were abandoned, or sexually abused, or a romantic interest convinced them to try a drug and they became addicted. It’s a fascinating behind-the-curtain look at the human condition.”

Sadly, one caring medical professional cannot fix a rampant societal problem.

“There are definitely cases that haunt you,” said O’Malley, “like the teenager who overdoses. There’s nothing more visceral than having a kid brought in by an ambulance and they’re dead and they stay dead, and you know that the parents are waiting for you to talk to them. You walk into the consultation room and see two people, sometimes only one, and they look at you and you realize that the next words you say are going to be the most important words they will ever hear. What language am I going to use to convey their new reality? It is very humbling.”

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Dorri Olds is an award-winning writer whose work has appeared in many publications including The New York Times, Marie Claire, Woman’s Day and several book anthologies. Find Dorri on Twitter, Facebook, and LinkedIn.