What’s more, Medicare calculates scores by tallying only the percentage of patients who rank a hospital a 9 or 10 out of 10 and/or who select “Always” in response to the specific questions. Not “Usually.” Not “Sometimes.” Not an average rating. “Always.” This is a lazy calculation that dismisses a tremendous amount of data. Technically, if a nurse rushes promptly to a patient’s bedside for every request—colder water, warmer blanket, lower shades—except one, then the hospital could lose credit for the question.

Medicare awards bonuses (out of the money withheld from hospitals) to the top-performing hospitals nationwide. Pitting hospitals against each other, the equivalent of grading on a curve, does not necessarily compare like with like. Already, results show that Washington, DC, and New York patients are less likely than other patients to give their hospital a top score. Several experts have pointed out that Midwestern patients complain less than crankier counterparts in the Northeast and California, where hospitals traditionally receive lower ratings.

Who gets the survey? Hospitals either call or mail the questions randomly to discharged adults, which theoretically could include drug-seeking patients who leave the hospital irate if the staff won’t give them prescriptions. Once, a patient who was in the hospital for chest pain asked Molly to take out her pessary (a small vaginal device), clean it, and reinsert it, not ER duties. When Molly told her she didn’t know how to remove it, the woman shouted, “I’m supposed to get it cleaned once a month and I’m a month overdue! It needs to be done now!” as if it were Molly’s fault she had skipped a doctor’s appointment. The hospital didn’t do it, risking poor scores because the staff rightly refused to meet the woman’s absurd demand. Another man complained to the hospital’s patient liaison because when the ER staff saved his father’s life, they lost his $8 undershirt. “Those are the people who get called for the survey,” Molly said.

While hopefully there aren’t many unreasonable patients who would avenge unwarranted anger on the survey, they do exist. The survey questions and methodology, however, don’t necessarily elicit an accurate portrayal of care quality. The survey doesn’t ask whether the hospital resolved or improved the patient’s medical issue, which one would hope would be the primary determinant of a patient’s satisfaction with the experience.

A national study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next four years.

UC Davis professor Joshua Fenton, who conducted the study, said these results could reflect that doctors who are reimbursed according to patient satisfaction scores may be less inclined to talk patients out of treatments they request or to raise concerns about smoking, substance abuse, or mental health issues. By attempting to satisfy patients, healthcare providers unintentionally might not be looking out for their best interests. As the New York Times nurse columnist Theresa Brown observed, “Focusing on what patients want—a certain test, a specific drug—may mean they get less of what they actually need. In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can’t, at the expense of what it should.”

The surprise

Hospitals, too, can offer poor care and still get high patient satisfaction ratings, and an alarming number of them do. In my research for this book, I examined Medicare’s provider data for thousands of hospitals—the data on every hospital in the country that the agency makes publicly available. I found the hospitals that perform worse than the national average in three or more categories measuring patient outcome. These are hospitals, in other words, where a higher number of patients than average will die, be unexpectedly readmitted to the hospital, or suffer serious complications. And yet two-thirds of those poorly performing hospitals scored higher than the national average on the key HCAHPS question; their patients reported that “YES, they would definitely recommend the hospital.”

As a Missouri clinical instructor said, “Patients can be very satisfied and dead an hour later. Sometimes hearing bad news is not going to result in a satisfied patient, yet the patient could be a well-informed, prepared patient.”

How far will a hospital go to satisfy a patient? In 2012, when the white father of a newborn baby at Hurley Medical Center in Michigan requested that no black nurses care for his child, the hospital complied. Tonya Battle, a neonatal intensive care nurse for twenty-five years, was reassigned to another patient. Battle sued the board of hospital managers and a nurse manager for discrimination. Hurley settled, paying Battle $110,000 and two other black nurses $41,250 each.

Surely, many patients are both honest and savvy enough to perceive and report the quality of their treatment accurately. But patient opinions and emphases vary widely. A 2012 study found that 61 percent of patients at hospitals with low scores on heart failure process measures (whether certain highly recommended treatments are provided to patients) said they would recommend the hospital to family and friends. Furthermore, about 40 percent of the worst-performing hospitals that treat heart failure reached the top half of patient satisfaction ratings, and 40 percent of the best-performing hospitals were in the bottom half. It is clear that the standard national surveys, developed by the Agency for Healthcare Research and Quality at the request of CMS, don’t provide patients the opportunity to appropriately evaluate their care.

Notably, the survey never indicates to patients that hospital funding is tied to its results. The survey’s recommended sample cover letter to patients states vaguely that the survey “is part of an ongoing national effort to understand how patients view their hospital experience.” That’s a major understatement. If patients knew how important the survey was, they might be more conscientious about completing it.

Gaming the system

Much like universities try to influence the U.S. News & World Report Best Colleges rankings by gaming the system and misrepresenting the data, many hospitals are doing whatever they can to beguile patients into giving them higher ratings. Recently, hospitals have rushed to purchase extra amenities such as valet parking, live music, custom-order room- service meals, and flat-screen televisions. Some are offering VIP lounges to patients in their “loyalty programs.”

The University of Toledo Medical Center spent approximately $50 million to renovate its hospital entry area, make all rooms private, change food and valet service vendors, and hire an executive chef. In Michigan, Beaumont Hospital spent $500,000 to install room service and a new menu including made-to-order omelets. As a Michigan consultant said, “One bad meal can mean a bad patient satisfaction score.” It’s probable that private rooms could give patients more rest, and tastier food could tempt patients into better nutrition. But some of that money, as at any hospital, could have been used to hire additional nurses, which would improve patient health more directly.

Because almost every question on the survey involves nurses, some hospitals are forcing them to undergo unnecessary nonmedical training and spend extra time on superfluous steps. Perhaps hospitals’ most egregious way of skewing care to the survey is the widespread practice of scripting nurses’ patient interactions. Some administrators are ordering nurses to use particular phrases and to gush effusively to patients about both their hospital and their fellow nurses, and then evaluating them on how well they comply.