Is the Affordable Care Act responsible for motivating hospitals to provide tastier menu options? Many hospitals are saying yes.

“I think that’s probably the biggest thing that’s changed and there’s always emphasis on quality —especially for those that are managing more than just food service. They have to meet those targets in terms of patient satisfaction,” says Lisette Coston, executive director of support services at Saint Francis Health System.

Last summer, widely-read media outlets such as USA Today and MSN News were touting healthier, tastier, more sophisticated menu choices as an unintended but welcome side effect of the federal health care law, which started tying patient-satisfaction scores with Medicare reimbursements over a year ago.

Since October 2012, a hospital can earn a 1 percent bonus, or be penalized up to that amount with Medicare and Medicaid patients, based partly on patient satisfaction surveys. By fiscal year 2017, that amount climbs to 2 percent.

However, these survey-based reimbursement bonuses may open up a new can of worms, since patient satisfaction can be broad, nebulous and subjective.

By most official accounts, these patient-satisfaction surveys were put together in such a way as to exclude any explicit mention of extra amenities or luxuries that did not tie in with what Medicare defined as quality of care.

But at the end of the day, when patients are asked to rate hospitals, such hotel-style luxuries inevitably factor into their assessment of the facility, and thus their satisfaction scores.

Word of mouth among hospital executives suggests that the quality of the food does have a significant impact on scores. While there’s no hard, conclusive evidence to back up this anecdotal assertion just yet, John Romley, research assistant professor at the Price School of Public Policy at the University of Southern California and economist at the Schaeffer Center for Health Policy and Economics, says that an initial analysis performed on his current research-in-progress indicates that amenities such as food may, indeed, be a driving factor in these scores.

If this turns out to be the case, then the implications for health care are significant: “Then the bonuses we’re awarding are actually rewarding amenities,” says Romley.

Many hospitals unable to afford costly renovations and fancy amenities are already worried. Such nonclinical enhancements don’t come cheap, costing hospitals significantly more than clinical improvements.

Hospitals serving lower-income areas that are already not out to make a profit may fall even further behind if their patient satisfaction scores can’t compete with swankier facilities modeled after the Marriott.

Lip service
The question becomes even thornier as experts delve further into the causal relationship between patient satisfaction and patient outcome. One doesn’t necessarily follow from the other, it turns out.

For at least some patients, amenities are actually more important than their quality of medical care. Researchers from the Hospital Consumer Assessment of Healthcare Providers and Systems examined data on Los Angeles-area Medicare patients who needed hospital treatment for pneumonia between 2000 and 2004.
It turns out that many of them chose not to go to the hospital closest to them, but the ones they did pick weren’t necessarily the ones with the best “risk-adjusted rates of death” — meaning they were drawn to other positives that weren’t tied to clinical outcomes or proximity.

The researchers also cited a recent survey published in the New England Journal of Medicine that found patients believe that a hospital’s “nonclinical experience” matters twice as much as its “clinical reputation.”

And in 2012, a team of UC Davis researchers published a troubling study that found that people who are the most satisfied with their doctors are more likely to be hospitalized, accumulate more health care costs, and actually have higher death rates than patients who are less satisfied with their care.

For every 100 people who died over an average period of nearly four years in the least satisfied group, about 126 people died in the most satisfied group.
While it may seem radically counter-intuitive that patient satisfaction and positive patient outcomes could potentially be so far apart, researchers blame at least part of it on a knowledge gap — traditional measures of clinical quality are often hard for laypeople to understand. “Consumers may be making choices on the basis of amenities because they are easier to understand,” researchers at the Hospital Consumer Assessment of Healthcare Providers and Systems wrote.

A free market economist might argue that such scores do what they’re supposed to do: give patients what they want. But it’s unclear whether patients who are unduly influenced by amenities are making an informed choice, or whether they would choose differently if they were properly educated and informed on quality of care when evaluating hospitals.

Of course, this isn’t to say that all amenities are unrelated to patient health. Some pioneering research around evidence-based architecture and design in health care is finding correlations between certain aesthetic and environmental features such as open windows, music, flooring and furniture arrangement and a boost in clinical outcomes.

Certain health professionals have been won over by the idea of selling a holistic patient experience rather than a patient outcome. “When this first started as a clinician, I thought, wow we’re pulling dollars away from the clinical. But patients actually heal better if they have a better sense of wellbeing so the other things that go into it — the way we treat a patient, talk to a patient — really does influence their clinical outcome. The culinary experience and hospitality work together to improve the whole experience of the hospital,” says Laura Watson, President of the Association for Healthcare Foodservice and System Director, Patient Support Services at Intermountain Healthcare.

Yet if such design and hospitality choices actually make a real impact on patient care, it’s all the more reason to tie them back to hard clinical evidence to ensure that the public is paying for measurable outcomes, not frivolous perks.

In the midst of ongoing national scrutiny and discussion around bloated health care spending, Romley points out, it’s important to be able to justify exactly what we’re getting for our money.

Health nut
As the debate around amenities carries on, one thing seems to be above debate: nutritious, delicious food represents both a perk and a measurable health outcome.

In particular, room service models seem to be catching on with hospitals both because it allows for a more flexible eating schedule for the patient while reducing food waste. “In the old model when we just sent a tray that was a full balanced meal — what if you only felt like having soup? The rest of the food was wasted. If you’ve only ordered soup now, you can order in a couple of hours if you’re hungry again,” says Watson.

Experts all agree that health and wellness continues to be a focus for hospital food services. “Really, there is an expectation that we’re contributing to keeping people out of the hospital,” Watson adds.

Of course, this effort isn’t without its challenges — people don’t necessarily want what’s good for them. To try to make healthy eating more accessible to patients, at Intermountain, executive chefs have teamed up to create LiVe Well Plates, or meals developed with specific criteria including a 600 calorie, 30 percent fat limit.

“These are new grains we’re showing people that they may not be purchasing at the grocery,” says Watson. The plate comes with a recipe so patients can easily recreate the meal at home.

People are also increasingly demanding meals with convenience, according to experts. “Patients are gravitating toward more of a grab and go type of item – everyone seems to be in a hurry. We’ve probably tripled the number of sandwiches and wraps and fruit parfaits,” says Saint Francis’ Coston, who reports that her facility redesigned its cafeteria to include a huge grab n’ go cooler.