Fake-Patient Survey May Help Primary Care, Say ACP, AAFP

June 27, 2011

June 27, 2011 — Some clinicians may feel spied on, but a federally funded survey using fake patients to determine how hard it is to get an appointment with a primary care physician may ultimately help improve paltry Medicare and Medicaid rates, according to leaders of 2 medical societies.

As supported by anecdote and survey alike, subpar reimbursement by government health programs deters many physicians from treating such patients. Yul Ejnes, MD, chair of the Board of Regents of the American College of Physicians (ACP), said that data from the proposed federal study could convince lawmakers to increase Medicare and Medicaid rates to ensure access to care, especially for aging Americans.

"It's understandable physicians would be concerned about someone misrepresenting themselves and asking for information, but good could come of this if it supports our case," Dr. Ejnes told Medscape Medical News.

The business world has long used so-called mystery shoppers — field researchers posing as potential customers — to find out if sales clerks are polite to customers or hotel hallways are clean. Not to be left out, healthcare organizations have hired mystery shoppers to study the patient's experience in a waiting room or exam room.

On April 28, the Federal Register published a proposal for a mystery-shopper study by the Department of Health and Human Services (HHS) that would assess the availability of primary care physicians who accept new patients and the timeliness of care from such physicians. Under the proposal, fake patients would telephone 465 primary care physicians (including pediatricians and obstetrician/gynecologists) in 9 states — Florida, Hawaii, Massachusetts, Minnesota, New Mexico, North Carolina, Tennessee, Texas, and West Virginia — and request appointments for both urgent medical needs and routine exams. If an appointment is made, the fake patient will cancel it at the end of the call. Each physician would be contacted twice, once by a field researcher claiming to have private insurance, and another time by someone who says he or she is covered by Medicare or Medicaid.

Insurance status is a critical variable to study because many physicians turn away Medicaid patients because of the program's meager reimbursement. Medicare patients are beginning to get the same treatment, by all accounts, as a result of draconian pay cuts that get postponed from year to year.

In addition, 11% of the physicians will be phoned and interviewed a third time about appointment availability by researchers who identify themselves as such. The purpose of this third contact is to determine whether the mystery-shopper approach yields accurate data.

Final Report Will Not Identify Individual Physicians

The overriding reason for the survey, HHS states, is to gauge the supply of primary care physicians just as the new healthcare reform law is creating a greater demand for these clinicians by extending insurance coverage to an additional 32 million Americans by 2019. HHS wants to know not only whether these individuals will find a physician but also how long they will have to wait for an appointment. In a funding application filed with the Federal Register, HHS cites a recent survey showing that the average wait time for an appointment with a family physician ranged from 2 to 3 weeks or more in 15 major metropolitan areas.

HHS will be accepting comments on the proposal for the mystery-shopper survey through the end of Tuesday, June 28. "After the public has a robust opportunity to weigh in, we will decide how best to move forward," HHS spokesperson Chris Stenrud told Medscape Medical News.

However, it is not clear how much has already been decided. The New York Times reported today that the National Opinion Research Center (NORC) at the University of Chicago has already signed a contract with HHS to help conduct the study. NORC research scientist Jennifer Benz, PhD, told Medscape Medical News that her center would indeed perform the study, but a higher-ranking NORC official referred all questions to HHS. Stenrud said NORC's involvement so far has been to draft the research proposal. Medscape Medical News requested a copy of the contract, which had not been supplied as of press time.

The results of the study could be published as early as the first quarter of 2012, according to HHS. The final report will present aggregate data only, with information identifying individual physicians stripped out. HHS estimates that the study will cost $347,369.

"Asking a Stupid Question"

Several physicians interviewed by the New York Times on the proposed survey objected to the prospect of "government snooping" and spying. In contrast, Glen Stream, MD, the president-elect of the American Academy of Family Physicians (AAFP), said he does not necessarily agree that the survey is intrusive.

"I think that 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," Dr. Stream told Medscape Medical News. His multispecialty medical group in Spokane, Washington, hires mystery-shopper patients from time to time, he added.

Like the ACP's Dr. Enjes, Dr. Stream points to the threat of Medicare pay cuts regularly triggered by the program's sustainable growth rate formula. On January 1, 2012, physicians face a nearly 30% reduction unless Congress once again steps in to avert catastrophe.

In an AAFP poll last fall, according to Dr. Stream, 13% of family physicians said a Medicare pay cut of such proportions would force them to close their practice.

While Dr. Stream and Dr. Enjes contend that the stealth survey could strengthen the case for raising Medicare and Medicaid rates, the leader of another medical society suggests that the study merely beats a dead horse.

"Why are they spending so much money asking a stupid question to which they should know the answer?" said Jane Orient, MD, executive director of the American Association of Physicians and Surgeons. "Doctors don't want to see more Medicare and Medicaid patients because they are so poorly paid and so badly treated. I don't know what they [HHS] can possibly learn from this."

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