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Dear CMS – Saying No Doesn’t Make Me a Bad Doctor

February 16, 2018

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This may come as a shock, but when you tell patients no, it negatively impacts patient satisfaction.  But that doesn’t make you a bad doctor, regardless of what CMS says.

Why does this matter?
Sometimes saying no to a patient is the right thing to do.  Evidence about the impact of this on patient satisfaction has been conflicting.  Physician compensation is often based on patient satisfaction scores.  Now hospital reimbursement is contingent upon outcomes-based scores, which include a US federal metric for patient satisfaction, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) score.  Clinicians are caught in between – do the right thing by refusing some patient requests (or demands) but in doing so face adverse personal and corporate financial consequences.

My kids: “Can we have cotton candy for breakfast?”
Me: “No.”
CMS: “You’re a bad father.”

This was a cross sectional study of 1319 outpatient visits to a group of family physicians that examined denial of some patient requests and effect on patient satisfaction based on the CAHPS score.  They found that physician denial of referral, pain medication, other new medication, or laboratory test decreased adjusted mean patient satisfaction percentile by -19.75, -10.72, -20.36, and -9.19, respectively.

There are two take home points from this study.

  1. We need training to mitigate the adverse impact when we must deny certain requests.
  2. Physician and hospital compensation based on patient satisfaction needs to be reconsidered or completely uncoupled.

Association of Clinician Denial of Patient Requests With Patient Satisfaction. JAMA Intern Med. 2018 Jan 1;178(1):85-91. doi: 10.1001/jamainternmed.2017.6611.

Peer reviewed by Thomas Davis, MD.

What are your thoughts?