Administrative Burden and Patient-Provider Communication Quality: Evidence From 11 Years of the Medical Expenditure...

Patient-provider communication quality, measured through the CAHPS programme that underpins Medicare value-based purchasing for over 200 million Americans, is among the most consequential evaluation metrics in healthcare. Although clinician and patient predictors of CAHPS scores have been studied, structural features of healthcare systems-in particular the administrative burden patients navigate through forms, prior authorisations, and billing bureaucracy-remain unexamined. This gap has direct implications for clinical practice evaluation: if administrative burden independently predicts the metric used to assess provider performance, risk-adjustment models may systematically disadvantage providers serving high-burden populations.

To provide the first national estimate of the burden-communication association, to evaluate robustness through a multi-framework sensitivity architecture, and to quantify equity implications across education and insurance subgroups.

Cross-sectional analysis of 9 MEPS waves (2012-2023; N = 110,459 US adults). Administrative burden was operationalised as a four-grade exposure from healthcare form encounters, with Grade 1 as the methodologically justified reference. We deployed IPTW via generalised boosted models, complemented by five sensitivity frameworks: negative control calibration, E-values benchmarked against CAHPS determinants, Oster bounds, health literacy calibration, and reverse-specification analysis.

Heavy administrative burden was independently associated with 10.8 to 13.3 percentage points lower probability of optimal communication across all four CAHPS domains (all p < 0.001), exceeding disparities by education and insurance. Negative control associations were 3-4x weaker; E-values (1.58-1.71) exceeded the strongest CAHPS determinants. The gap was steepest among lower-education (-15.2 pp) and publicly insured (-14.3 pp) adults. Reverse-specification analysis demonstrated asymmetric directionality.

In this first national quantification, administrative burden was independently and robustly associated with substantially lower communication quality. These findings position administrative complexity as a structural correlate of clinical encounter quality, and identify administrative simplification-grounded in SQUIRE-guided quality improvement-as a modifiable pathway for improving patient experience in disadvantaged populations served by clinical practice evaluation frameworks.