Why Secret ‘Doctor Shopping’ Studies Are Necessary

Are primary-care doctors prioritizing patients by their insurance status? Why audit studies are necessary to ensure equitable access to medical care in the U.S.

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ER nurse: “Can Mrs. Jones be discharged?”

ER doctor: “I don’t know. She probably doesn’t need admission to the hospital today, but she does need follow-up with a doctor very soon. I am worried, though, that Mrs. Jones isn’t plugged in.”

This is a common refrain in emergency rooms across the country. In the course of treating patients, doctors sometimes find problems that are not immediately life-threatening but need to be addressed urgently by another doctor outside of the ER. But that transfer of care isn’t easy if a patient isn’t “plugged in.”

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In medicine, we use that term casually, but it touches on some fundamental issues inherent in our health care system. From a health-policy perspective, being plugged in refers to two major topics central to the health-reform debate: access and transitions.

Access means the ability to see an outpatient doctor in a timely way. In the case of Mrs. Jones, who was treated for a twisted ankle but was also found to have previously undiagnosed sky-high blood pressure, it meant having immediate access to a specialist. The blood pressure wasn’t going to kill her that day, but if left untreated, it would soon cause serious heart, kidney and brain problems.

Transitions refers to the coordination of patients’ care between one health care location (like an ER or a hospital) and another (like a clinic). Many recognized problems — like high blood pressure in patients like Mrs. Jones, who doesn’t have a regular doctor — fall through the cracks as patients go from one doctor to the next.

The health-reform law seeks to fix these problems by providing more Americans with health insurance (improving access) and using financial incentives to encourage doctors and hospitals to talk to one another (improving transitions).

But from the trenches of the ER, it isn’t so simple. The reality is that neither possessing health insurance nor having nice, clear hospital-discharge instructions guarantees that a patient will get an appointment with the right type of doctor in the right amount of time. For patients, this causes supreme frustration, and sometimes leads to untreated problems and worse outcomes. For doctors, not knowing how or if patients will get timely follow-up affects our medical decisions.

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Indeed, ER patients are sometimes admitted to the hospital precisely because it is impossible to ensure that they will be seen by another doctor in a timely way. This happens even though hospital stays can sometimes trigger new problems, like hospital-acquired infections or the ordering of unnecessary tests, not to mention result in higher health care costs. Many times, the alternative — discharging an ER patient with an urgent medical need who may experience a bad outcome if they can’t get quick follow-up — is just not good care.

So exactly how plugged in are Americans? According to a recent New England Journal of Medicine (NEJM) study, the answer depends not on whether you have insurance, but on what type of insurance you have. The study found that children with Medicaid (public insurance for the poor, which is the coverage Mrs. Jones had) who had conditions that required rapid specialty follow-up had to wait longer for an appointment than kids with private insurance. This is likely because doctors get paid more for appointments with privately insured patients than with Medicaid patients, so prioritizing the privately insured is financially attractive.

But how do we know that doctors are giving preference to the privately insured? The Medicaid study used “auditing,” a method by which fake patients call up doctors’ offices claiming to have conditions that require urgent treatment or evaluation; patients pretend to have either public or private insurance. That’s the same strategy that the U.S. Department of Health and Human Services (HHS) announced it would use in a study of doctors’ offices in nine states designed to determine whether primary-care doctors were prioritizing patients by insurance status. Following the HHS announcement, however, doctors objected vociferously to the government’s snooping into their office scheduling policies.

Studies that rely on auditing (also known as secret doctor shopping) invite objections for visceral reasons. First, it feels unseemly to use such deceptive practices to evaluate doctors and hospitals. Second, there’s the Big Brother issue: according to Dr. Karin Rhodes, an expert on audit studies and the author of the NEJM Medicaid study, people tend to oppose audits even more when it’s the government conducting them. But in the end, is it not the government that pays doctors to see patients with public insurance, including Medicaid? Audit studies offer valuable information that would not be possible to get if the research were not designed in a deceptive way. And to be fair, audits don’t publicize the names of the doctors or hospitals they target.

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We argue that audit studies are necessary to ensure equitable access to medical care in the U.S. Too bad, then, that the government’s plan to conduct these audits was scrapped because of the outcry.

The truth is, the barriers to good medical care are complicated. The public debate on health insurance and health reform is often framed around whether patients have access to medical care or not. But simply having access isn’t the same as being plugged in. For some — like Mrs. Jones, who needs timely specialty follow-up after an ER visit — it means being assured of an appointment with the right kind of doctor in a day or two. For others, it means having a health care provider who is available to answer questions about an ongoing medical problem. For still others, access means being able to get to the doctor’s office without resorting to dialing 911.

In the coming years, as the U.S. broadens health coverage, it will be vital to learn more about the best ways to ensure that people get the right type of follow-up care in the right amount of time. Audit studies are an important part of this process and should be reconsidered.

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