Unsolved Mystery: Could Secret Shoppers Have Helped Reform Law?

To be fair, the secret-shopper program wasn’t much of a secret anymore.

Trade publications had reported for weeks about the Obama administration’s plan — openly published in the Federal Register on April 28 — to use fake patients to survey thousands of primary care physicians about their wait times for appointments. The findings were supposed to inform the government’s strategy to implement health reform, given the enormous expansion of health coverage under last year’s law.

But a New York Times front-page story on Monday took the project from health policy circles into the echo chamber of cable TV and talk radio.

Within 48 hours, the plan was dead — and a new mystery emerged.

Why would anyone want to kill the mystery shoppers?

Whodunit in Two Days

An HHS spokesperson stressed that “politics did not play a role in the decision” to abruptly cancel the project. But all the clues point to a political assassination. HHS already had signed a contract with the University of Chicago’s National Opinion Research Center and mapped out a plan that would cost about $350,000. The survey was to include 4,185 PCPs across nine states and gauge overall availability, as well as differences between public and privately insured patients.

However, many critics argued there was a major flaw: The Obama administration was spending time and energy to find answers it already knew.

The dearth of PCPs and related patient access problems is no secret and, when filing its funding request for the survey, HHS cited findings that the average wait time for an appointment with a family physician ranged from two to three weeks or more in 15 major metro areas.

The Golden State has its share of access challenges. The California Medical Association cites a California HealthCare Foundation report that 74% of California counties have PCP shortages and warns that the state is “barely meeting” the Council on Graduate Medical Education’s minimum standards for primary-care doctor access. (CHCF is the publisher of California Healthline.)

The Affordable Care Act is projected to extend health insurance to millions of Americans, including four to five million Californians, which could only worsen physician access and availability problems.

One family physician told the New York Times that if the government was worried about patient access, “they could help us. They don’t have to spy on us.” Another internist said secret shoppers would be “a pernicious practice — Big Brother tactics, which should be opposed.” Republican lawmakers like Sen. Mark Kirk (Ill.) also jumped in with criticism.

Health policy experts say once the furor erupted, they knew the program was in trouble. “When I [saw] the ‘Big Brother’ comment … I recognized there was a political problem,” Anthony Wright of Health Access told California Healthline.

Ethics of Mystery Shopping in Health Care

Even the strongest advocates of secret-shopping programs acknowledge legitimate concerns when researchers pose as patients. Given the high stakes, the tolerance for fakery in health care is exceedingly low.

Secret shoppers are commonly used in retail or service industries, where the risk of complications is minimal. The worst case scenario in those sectors — a sales clerk is too busy with a fake client; a real customer suffers a fashion emergency? — pales next to health care, where a mystery patient could tie up needed time and resources.

So a successful secret-shopper program in health care “must not put other patients in harm’s way or cause needless delays,” John Swinburn, head of the Mystery Shopping Providers Association, told California Healthline. The government’s physician-access survey, supporters say, was designed to minimally burden providers for that very reason.

Of course, many large hospitals like Massachusetts General conduct their own secret-shopping surveys, in hopes of boosting the customer service experience. HHS also can point to a handful of its own recent efforts to mystery shop health care, which — as designed — occurred largely under the radar and led to improvements.

As Charles Fiegl notes in American Medical News, an HHS secret-shopper initiative found errors in 40% of Medicare Advantage sales events and spurred health plans to work on improving accuracy of drug coverage information. The department’s 2004 investigation into its own 1-800-MEDICARE phone line famously discovered that operators gave Medicare beneficiaries the right answer roughly 60% of the time — scarcely more accurate than flipping a coin.

Confused Providers Wonder if Opportunity Was Missed

Talking to providers and policy watchers, it’s tough to find a single association that’s happy the secret-shopping program is gone. Even physician groups acknowledged the irony of doctors leading the charge to kill a plan that could have helped them win federal resources and support.

Before the program was officially canceled, Dr. Glen Stream, the president-elect of the American Academy of Family Physicians, told Medscape Medical News that he expected “the data will only validate the concerns we have that there is an inadequate supply of physicians, and that patients won’t be well served until we address the problem.” Stream also noted that his own multispecialty medical group occasionally hired mystery shoppers to vet the practice.

Count the California Medical Association among the surprised groups, too. While the government’s survey would not have included the Golden State, a hypothetical California secret-shopper survey could have reaped interesting data. “We would love to know … the real experience of a Medi-Cal patient here,” CMA’s Lisa Folberg told California Healthline. Getting a real sense for patient access “isn’t just counting heads,” she said, adding that CMA has collected anecdotal stories of PCPs who “can’t find a specialist to take their [Medi-Cal] patient and have to call in chits with a friend from medical school,” even though Medi-Cal patients purportedly have plenty of specialist options.

Mystery shoppers could have also unearthed essential data about provider access that could be “an early warning system for deeper issues in the health care system,” like inadequate reimbursement, according to Wright of Health Access. This kind of work would have “provided the data and support” for federal and state reformers to target issues and better prioritize measures that affect physician supply, Wright added.

For now, the mystery patient program goes into the cold case folder. Here’s a look at other stories heating up health reform discussions.

Rolling Out Reform

• Last week, HHS announced $10 million in available federal grants for organizations that want to establish or expand workplace health promotion programs. The money is a part of the Prevention and Public Health Fund, which was created by the federal health reform law. The grants are intended for programs that aim to promote smoking cessation, reduce chronic disease risk factors and educate workers on the importance of physical activity and healthy diets (CQ HealthBeat, 6/23).
• In a recent Politico opinion piece, HHS Secretary Kathleen Sebelius defended the Independent Payment Advisory Board, saying its “work will be transparent, independent and accountable to Congress and the president.” IPAB will consist of 15 health experts tasked with making recommendations to Congress to reduce Medicare spending growth. Sebelius wrote that there are built-in restrictions on what the board can recommend, adding, “It is expressly prohibited from making recommendations that ration care, raise premiums, reduce benefits or change eligibility for Medicare.” She noted that Congress “will still have the final decision on any changes” (Sebelius, Politico, 6/23).
• Last week, CMS Administrator Don Berwick sought to allay concerns of hospital and physician groups over the implementation of accountable care organizations mandated by the federal health reform law. Berwick said that CMS is actively responding to criticisms and making required changes. Berwick also said the new Center for Medicare and Medicaid Innovation is attempting to develop advanced payment models so that “aspiring ACOs who lack front-end resources to start can have access to some financial support.” Berwick acknowledged criticism of the proposed shared savings ACO regulation but did not discuss any plans for changes (Adams, CQ HealthBeat, 6/21).

In the States

• Last week, the Third U.S. Circuit Court of Appeals in New Jersey heard arguments in a lawsuit challenging the constitutionality of the federal health reform law. The appeal comes after U.S. District Judge Susan Wigenton dismissed the case, ruling that the plaintiffs did not have the standing to bring the suit because a plaintiff could be covered by an employer’s health plan by 2014, when the individual mandate takes effect. In the appeals court hearing, appellate court Judge Michael Chagares said not enough is known about the current insurance status of the plaintiffs, hindering predictions of the law’s eventual effect. The judges did not say when they will rule on the case (AP/Washington Post, 6/22).
• This month, the Maryland Health Benefit Exchange Board of Trustees plans to apply for nearly $50 million in federal grants to set up the state’s new health insurance marketplace. The applications ask for a maximum of $3 million for administrative and operations staff; $2 million for policy development, planning and legislative studies; and between $40 million and $44 million for health information technology. The state is responsible for about 4% of total IT costs, while the federal Center for Consumer Information and Insurance Oversight and CMS are expected to contribute the remainder under the federal health reform law (Dance, Baltimore Business Journal, 6/21).
• New global payment models do not cost less than the fee-for-service system in Massachusetts, according to a new report issued by Massachusetts Attorney General Martha Coakley (D). Massachusetts has been a model for national health reform since the state enacted its 2006 health reforms. Global payment contracts generally call for paying physicians a fixed per-patient amount and include financial incentives for meeting quality goals and cutting costs. Coakley said global payments are a step in the right direction because they reward quality, but she suggested that Massachusetts adopt “temporary statutory restrictions on how much prices may vary for similar services” (Kowalczyk, Boston Globe, 6/23).

On the Campaign Trail

• Last week, Republican presidential candidate and former Minnesota Gov. Tim Pawlenty said he will continue to criticize the federal health reform law and fellow Republican presidential candidate and former Massachusetts Gov. Mitt Romney, who signed legislation four years ago overhauling his state’s health care system. Pawlenty continuously has expressed his opposition to all aspects of the federal reform law, including the individual coverage mandate and state-based health insurance exchanges. “It’s philosophically obnoxious and objectionable to have the government step in and tell you that you must buy health care, subject to a penalty,” he said (Kliff, Politico, 6/21).

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