Medical Access: An Audit

As I prepared to leave on holiday, the New York Times included a story by Robert Pear with the scary headline “U.S. plans stealth survey on access to doctors.” As Pear described, the National Opinion Research Center here at the University of Chicago had signed a $347,000 contract with the Department of Health and Human Services to conduct audit studies of more than 4,000 doctors in nine states.

By the time I returned, the study had politically imploded. That’s too bad….

Paralleling a recent study of Cook County providers by Rhodes and colleagues in the New England Journal of Medicine, NORC auditors would call each medical practice twice to request an appointment. Callers would follow an explicit script. In some cases, they would report a diagnosis that merits quick medical attention. In others, the caller would report more routine issues such as an annual school physical or a checkup. In one of the calls, auditors would report that they have public insurance such as Medicaid. In the other call, auditors would report having private coverage. Eleven percent of the providers received a third call for an identified survey researcher, who would inquire about whether these providers accept different types of insurance.

This study attracts predictably negative comment, particularly among doctors.

“I don’t like the idea of the government snooping,” said Dr. Raymond Scalettar, an internist in Washington. “It’s a pernicious practice — Big Brother tactics, which should be opposed.” …

Dr. Stephen C. Albrecht, a family doctor in Olympia, Wash., said: “If federal officials are worried about access to care, they could help us. They don’t have to spy on us.”

Two days later, things had predictably imploded. The proposed study was placed on “indefinite hold.”

Truth be told, pulling the plug made sense from a political perspective: The study’s big-brother optics were obvious. At this delicate moment, the administration could ill-afford to irritate a medical profession with whom it is negotiating so many other issues in health reform. Many doctors suggested that this $347,000 would be better-used to finance patient care. Utah Senator Orrin Hatch criticized the study as “wasting taxpayer dollars to snoop into the care physicians are providing to their patients.” A week later, I’m sure the administration is pleased this little pebble has sunk to the bottom of the pond, leaving barely a ripple.

On the substance, though, this little story illustrates why health policy is so hard to implement well, and why the policy process is so frustrating. Although Pear’s article has the flavor of a scoop, the study was discussed in the trade press and described in the Federal Register two months ago. Sherry Glied, HHS assistant secretary for planning and evaluation, was associated with this study. One of the nation’s leading health services researchers, she deserved better than what unfolded.

The federal government spends about $800 billion annually for medical care. It makes sense to spend 0.00004 percent of this princely sum for some intelligent investigation to go beyond the anecdotal in learning what we are actually buying (or trying to buy) with this massive sum. Two or three additional calls would not impose undue burdens on the tiny fraction of U.S. physicians chosen for this study. We spend millions of dollars surveying physicians about their attitudes and behavior regarding public and private insurance coverage. It would also be nice to have some independent check on the accuracy of these responses. In my view, physicians have a strong ethical obligation to participating in clinical and policy studies that can improve patient care.

Although the survey mechanics have not been the subject of public debate, audit studies raise important methodological concerns. The proposed study seemed well-designed to capture basic access problems. In the New England Journal study noted above, two-thirds of Chicago-area specialists would not schedule an appointment for Medicaid and CHIP recipients.

Such studies are less specifically tuned to capture more subtle access problems experienced by millions of low- and moderate-income people who hold various constrained forms of private coverage. Rhodes and colleagues compared Medicaid and CHIP with Blue Cross Blue Shield coverage that is arguably more generous than many low- or moderate-income families can readily afford. All things considered, it may also make sense to conduct audit studies outside the immediate purview of the federal government, for example as investigator-initiated academic research funded by the National Institutes of Health or the Agency for Healthcare Research and Quality (AHRQ).

Critics of the proposed study do make one argument that should be addressed. They argue, with considerable validity, that audit studies merely verify the obvious point that public insurance hinders access by providing low reimbursements. Many providers respond to this reality through their reticence to take publicly-insured patients, a problem that reflects both public policy failure alongside sometimes-questionable behavior within the medical community. We don’t need new studies to document that Medicaid pays far below the usual market rate, and that many providers therefore refuse to deal with it.

Given this reality, it’s particularly unfortunate that the administration opposes patient and provider efforts to sue states that fail to provide adequate reimbursement, and that further Medicaid provider reimbursement cuts are apparently on the table. Both liberals and conservatives have reason to know that this is bad policy.

The federal government and the states have allowed this problem to fester for decades. We don’t need a new study to demonstrate that providers, states, and the federal government must do better. We do need specific measures of barriers and progress to understand what’s going on. Verifying such access is not Big Brother, much as many patients could use one to gain access to needed care.

[Cross-posted at The Reality-Based Community]

Harold Pollack

Harold Pollack is the Helen Ross Professor at the School of Social Service Administration at the University of Chicago.