Secret Shoppers: Needing A Weatherman To Know Which Way The Wind's Blowing

Brian Klepper

June 28, 2011

Every now and then, a well-intentioned administration does something relatively harmless but so hare-brained and openly foolish that it takes our breath away. The Obama Administration’s primary care “secret shopper” plan fit this bill, and has already been shelved due to the withering criticism. My inbox a couple days ago was filled with rants by physicians of all political persuasions marveling at the lameness of the idea.

Here’s a short description from Robert Pear’s article in Sunday’s New York Times.

The administration says the survey will address a “critical public policy problem”: the increasing shortage of primary care doctors, including specialists in internal medicine and family practice. It will also try to discover whether doctors are accepting patients with private insurance while turning away those in government health programs that pay lower reimbursement rates.

That primary care access has been squeezed is hardly in question. Undervalue a critically important resource, make it a financially undesirable choice for young professionals and – Voila! – capacity drops. Having too few primary care physicians is the result of 20 years of systematic effort by the specialist-dominated American Medical Association, with theseeming oblivious complicity of both Democratic and Republican administrations.

Ironically, a new study answering a question related to the Administration’s project’s question was released last week and I noted it on this blog. Writing in New England Journal of Medicine, Bisgaier and Rhodes had research assistants pose as mothers trying to make pediatric specialty care appointments, with type of insurance as the only variable. Two-thirds (66%) of those who mentioned Medicaid/CHIP were denied appointments, compared with 11% of those who mentioned private insurance. In 89 clinics that accepted both kinds of patients, the waiting time for callers who said they had Medicaid was 22.1 days longer, on average, than for those who said they had private insurance.

So, yes, primary care doctor practices that have been under-funded as a matter of policy for two decades, are slammed and often hard to get into. And, yes, specialty practices are sensitive to programs that pay significantly less and, in general, make it harder for patients in those programs to gain access. Big news.

Finally, suggesting that any survey addresses a critical public policy problem is, to use Ben Franklin’s phrase, confusing motion with action. Even under the best circumstance, which this is not, a survey can reveal a subtle, previously unappreciated issue.

In this case, though, we know the problem. Primary care physicians’ work is consistently at least as complex and important as that of their specialty colleagues. They are underpaid relative to their specialty peers, whose work is often overvalued by the AMA’s Relative Value Scale Update Committee (RUC). These disparities are rooted in the failures of theResource-Based Relative Value Scale, a flawed methodology that appreciates inputs but not value, and CMS, which has permitted the RUC to use a financially-conflicted advisory structure and shoddy survey methodologies as the basis for momentous decisions that have strangled primary care while enriching specialty physicians at the expense of the American patients.

What is needed now is leadership. To move America’s health system forward, we need decisive payment reform that can replace our current valuation process with a more credible approach that appreciates evidence, complexity and value. We need to reassess overvalued procedures, and define new ways to pay for primary care physicians that create financial parity with specialists while holding PCPs accountable for their patients care and costs throughout the continuum. This is the only way to really begin to heal our broken health care system.