Hello, doc, I’m your mystery shopper

You know what my first reaction was to the federal government’s plan to use mystery shoppers to gauge how easy – or difficult – it is for patients to make a primary care appointment?

Bring it.

The concept has been getting a ton of negative feedback. Online critics are calling it “government snooping” and an “anti-doctor campaign.”

To recap: The Obama administration is recruiting a team of mystery shoppers to pose as new patients and call doctors’ offices to see how much effort it takes to get an appointment. One of the purposes of this research is to gauge the accessibility of primary care doctors – a key issue as millions of Americans gain health insurance coverage under provisions of the Affordable Care Act. Another purpose is to look at the extent to which physician practices might be accepting new patients with private insurance while turning away those on Medicaid and other public programs. The project, which is still only a proposal at this stage, will potentially be carried out in nine states, including Minnesota.

If this sounds subversive, consider the state of primary care these days.

It is a cold, hard fact that patients frequently have to wait several weeks to see a doctor for something that’s non-urgent. Those of us who live in rural communities encounter this reality every day. The last time I made a doctor’s appointment, the earliest available opening was seven weeks out. I’ve had other wait times ranging from 10 days to three weeks. For a specialist once, it was five weeks.

Is this a hardship? It wasn’t for me, but it might well have been for someone else. How many times do patients end up in an urgent care clinic or an emergency room because they couldn’t – or wouldn’t – wait that long?

Fact #2: Many primary care doctors already have full panels and are no longer taking new patients.

Last month the Massachusetts Medical Society released a report on wait times and physician access. Of the 838 physicians who responded to the telephone survey, 51 percent of internists and 53 percent of family doctors were not taking new patients. The average wait time to see an internist was 48 days; for family doctors, it was 36 days. Average wait times also were rising for specialists such as orthopedic surgeons, cardiologists and gastroenterologists.

Fact #3: An estimated 65 million Americans live in officially designated primary care shortage areas. Shortages are the worst in areas that are rural, poor and/or minority.

Fact #4: Publicly funded programs such as Medicaid (and, here in Minnesota, the MinnesotaCare program) are not attractive to physicians because of the paltry reimbursement. One of the most severe access problems in Minnesota is with dental care for individuals on MinnesotaCare, because so few dentists will take these clients. It is not mandatory for providers to accept Medicaid, MinnesotaCare or any of the other public programs – but when they opt out, access inevitably is diminished.

Fact #5: Access is integral to the overall functioning of the health care system. When patients do not receive timely access to care, the result can be more use of expensive emergency care, higher risk of hospital admissions and readmissions, inadequate management of chronic diseases and worse health outcomes.

I would have cringed if the mystery shoppers pretending to be patients were actually coming to the clinic and using valuable appointment time needed by real patients. Based on what I’ve read about this initiative, however, it doesn’t appear to extend beyond the appointment-making process.

To those who are already familiar with the primary care shortage, this entire proposal may sound like a product of the Department of Duh. But if the federal government is serious about addressing what ails primary care, which is the better strategy: collecting hard evidence or relying on anecdote, perceptions and personal experience?

There’s also something valuable about measuring physician access from the perspective of patients themselves – even if the patients are secret-shopper fakes. Most of what we currently know about wait times and provider shortages is derived from surveys of physician practices and insurers, not from patients. No matter how much clinicians and policymakers think they know about the patient experience, they can’t claim to truly know if they don’t include the patient’s viewpoint in their data collection.

If I have any reservations about the mystery shopper proposal, it’s this: When reimbursement for Medicaid, MinnesotaCare and other publicly funded health programs is so disappointing, there’s virtually no incentive for any practitioner to want to see these patients. It’s easy to criticize them for their refusal yet overlook how they’re financially penalized when they do accept patients on public programs. This is an untenable situation for everyone involved, and it’s to be hoped that the information collected by the mystery shoppers will lead to some genuine and constructive change.

If there’s a better way to collect patient access data than by using mystery shoppers, I’m all ears. In the meantime, it’s hard to see how a physician with a well-run practice would have much to fear from a phone call from a government-funded mystery shopper.

Addendum: Here’s the posting in the Federal Register.

Update, June 29: The heat appears to have been too much; the Obama administration announced yesterday it has shelved its plans for the mystery shopper survey. Perhaps the idea was a public-relations disaster from the start – but it was dismaying to see how much of the debate was focused on the survey methods rather than on the bigger picture of access to health care. Doctors and politicians seem to have had plenty to say; where’s the voice of patients?

Image: Wikimedia Commons

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