Why HHS abandoned "mystery shopper" study

The Obama administration changes course after lawmakers and physicians decried a plan to survey practices secretly.

By Charles Fiegl — Posted July 11, 2011

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A proposed initiative using so-called mystery shoppers to determine the level of access to primary care physicians across the country has been put on hold indefinitely following scrutiny of the proposal.

The Dept. of Health and Human Services decided June 28 not to go forward with the proposed study after reviewing public comments on the plan, an HHS official said. Instead, the department said it will continue to focus on other initiatives aimed at increasing access to health care services.

HHS had first published a notice about the study on April 28. The $347,000 study would have targeted more than 4,000 family medicine, pediatric, general medicine, internal medicine and obstetrics-gynecology practices in nine states: Florida, Hawaii, Massachusetts, Minnesota, New Mexico, North Carolina, Tennessee, Texas and West Virginia, according to supporting documents from HHS. The practices would have been contacted by a mystery shopper once pretending to have private insurance and a second time posing as an enrollee in a public health program. Additionally, 465 practices would have been called a third time. The caller would have informed the practice of the study and asked if it accepted new patients and how long it would take to get an appointment.

Documents for the proposal listed several scenarios for publicly and privately insured patients. The mystery shopper would have used a script to determine if the practice accepted new patients and if the practice accepted a certain type of insurance more readily than another. One scenario involved a mystery shopper with private insurance who needed to see the doctor as soon as possible. The script included a list of symptoms that the caller would have stated when prompted by the front desk staff.

"I've had a cough for the last two weeks, and now I'm running a fever," the caller would say. "I've been coughing up thick, greenish mucus that has some blood in it, and I'm a little short of breath."

But that script might have failed to produce the results HHS was looking for, said Glen Stream, MD, president-elect of the American Academy of Family Physicians. Physician office staff probably would have recommended that the caller seek urgent care under those circumstances instead of scheduling an appointment, he said.

Regardless of the proposal's details, Dr. Stream said HHS does not need to take a mystery shopper approach to gauge access to primary care physicians. He suggested a more direct approach of asking physicians whether they accept patients with public health plans and how long patients wait for an initial appointment.

AAFP found 71% of family physicians are accepting new Medicare patients, according to a September 2010 study. Physicians also were asked how Medicare payment cuts would impact their practices. Nearly 75% said they would limit Medicare appointments, and 62% said they would stop accepting new Medicare patients.

Before HHS rescinded the proposal, American Medical Association Immediate Past President Cecil B. Wilson, MD, said in a statement that similar studies have shown that patients have experienced access issues when it comes to primary care. "The government should be working to address this shortage so all patients can have access to the health care they need, rather than using mystery shoppers to tell us what we already know," Dr. Wilson said.

Detractors of the proposal suggested that the Obama administration was attempting to ensnare physician practices by catching office staff in a lie or demonstrating that practices discriminated against patients with public insurance.

But, in general, limiting the number of Medicare patients compared with the number of appointment slots for private pay patients is not going to get practices in legal trouble, said William Maruca, a health care attorney at Fox Rothschild in Pittsburgh. Physicians and practice administrators often set ratios for the right payer mix to keep practices financially sustainable.

Depending on the insurer, some contracts for Medicare managed care might include language stating that practices can't turn away new patients, Maruca said. Individual states also may have laws against restricting access to patients with Medicaid coverage.

"But it's permissible as far as traditional Medicare itself is concerned," he said.

Uproar precedes about-face

The mystery shopper plan was first reported by American Medical News on June 6. An article about the initiative appeared on the front page of The New York Times on June 27, the day the comment period on the survey ended.

HHS says that the decision to pull the plug on the idea the following day was based on the public comments the department received, not any political pressure. House Republican Policy Committee Chair Tom Price, MD (R, Ga.) was among several Republicans in Congress who cited the Times story and criticized the administration for attempting to "spy on" physicians.

"I was relieved to hear that HHS was suspending this program," Rep. Michael C. Burgess, MD (R, Texas), said on June 30. "The approach that HHS planned to take would yield unintended consequences and would have only further driven physicians away from public insurance. The 'mystery caller approach' does not serve the integrity of these public programs or their beneficiaries."

In a letter to HHS Secretary Kathleen Sebelius, Dr. Burgess said the programs' design and meager pay for services are disincentives to physician participation in Medicare and Medicaid. Participation will continue to decline without major changes, such as meaningful medical liability reform and a long-term fix to Medicare's payment formula, he said.

The Obama administration has made recruitment and retention of primary care professionals a top priority, an HHS spokesman said in a statement. The Economic Stimulus Act of 2009 and other federal investments will train more physicians and encourage them to practice in underserved areas.

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Going mystery shopping

The use of mystery shoppers is not new for the federal government. The practice involves researchers acting as consumers to gauge the quality or accuracy of the information or services that a real consumer might receive. Here are some examples in which the federal government has used mystery shoppers:

  • The Centers for Medicare & Medicaid Services as recently as 2010 deployed secret shoppers to monitor marketing and sales events by Medicare private plans.
  • The National Community Reinvestment Coalition in 2009 used mystery shoppers posing as borrowers delinquent on mortgage payments to identify troubling foreclosure prevention practices.
  • The Government Accountability Office in 2008 shopped retail stores to determine preparedness for the converter box subsidy program before the digital television transition.
  • The U.S. Citizenship and Immigration Services in 2006 received calls from mystery shoppers to evaluate answers provided by the bureau.
  • The GAO in 2004 used secret shoppers to call Medicare's hotline, 800-MEDICARE, to examine customer service representatives' responses to patient questions.

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