New Study: I3PI “Secret Shopper” Patients Improve Medical Care, Documentation, and Spending
Actors working for the Institute for Practice and Provider Performance Improvement, Inc. (I3PI) made undercover visits to New Jersey doctor’s offices to gather information about how doctors treated common conditions. Doctors substantially improved in the care they provided for smoking cessation, back pain, and depression, wrote more accurate notes, and spent less in treating diabetes and depression in their actual patients compared with other practices.
According to Alan Schwartz, PhD, I3PI principal and lead author, the study, published in the Journal of General Internal Medicine and conducted in partnership with the American College of Physicians and Horizon Healthcare Services, Inc., is the first to demonstrate that medical secret shoppers (also known as “unannounced standardized patients”) can not only identify areas to improve care but can have impacts on insurance claim patterns among real patients of practices visited. Meshie Knight, program officer at the Robert Wood Johnson Foundation, which provided funding for the study, explained, “Like most of us, providers value opportunities for concrete and constructive feedback in order to improve—both in terms of remediating errors of omission and commission, but importantly in ensuring that the care people receive takes into account the reality of their lives—appropriately meeting their goals and their needs. Unannounced standardized patient (USP) programs allow us to assess health care delivery from the patient’s perspectives. They provide a unique window into patient-provider care encounters that benefit both patient and provider.
The doctors, working at 22 practices across New Jersey, agreed to participate in the program, not knowing when they would receive visits from actors. Most were visited by two actors, given feedback about the visits, and then visited by two more actors, over about 12 months. The actors carried concealed recorders and used the same scripts for each doctor they visited, so feedback could show doctors how they performed compared with many others seeing the same “patient.” In addition to studying the care delivered and documented in the medical record, Horizon, New Jersey’s oldest and larger health insurer, helped I3PI compare changes over time in patterns of insurance claims between the participating practices and a similar group that did not have secret shopper visits. “Directly observed care provides meaningful and actionable feedback to clinicians that is not available through traditional surveys,” said Steven Peskin, MD, MBA, Executive Medical Director Population Health and Transformation at Horizon and a study co-author. “The secret shopper program yielded tremendous insights for the 59 clinicians that participated. We were delighted by the level of commitment by the practices, the quality of the information gathered by the actors, and the openness to feedback among our participating clinicians.”
Doctors performed 53% more recommended clinical practices in the post-feedback visits than the pre-feedback visits, particularly in smoking cessation (e.g. discussing cessation strategies), managing chronic low back pain without opioids, and screening for depression. Notes from post-feedback visits were also 26% less likely to report physician behaviors that had not actually occurred (e.g. documenting a diabetic foot exam not conducted). Office visit claims by actual patients of participating practices in periods before and after the visits compared with similar nonparticipating practices showed slower spending increases for patients with diabetes and depression (where better management leads to fewer office visits) and higher spending increases for patients with back pain (where physical therapy claims increased, consistent with reduced use of opioids) and increased cancer screenings. Patients with diabetes in participating practices saved an estimated $842 in claims per patient over a year.
“One of the best things about secret shopper studies is that they don’t require doctors do anything but provide usual best care,” explained Saul Weiner, MD, I3PI principal and study co-author. “As we move to value-based care and value-based payment systems, measuring quality is critical. The unannounced standardized patient approach is the only one that measures quality through direct observation of the patient-doctor interaction,” added Alan Spiro, MD, MBA, I3PI principal and study co-author.
Read the full results of the study in the Journal of General Internal Medicine on July 7, 2020 (http://dx.doi.org/10.1007/s11606-020-05965-1). Further findings related to depression screening have also been published in DIAGNOSIS on March 18, 2020 (https://doi.org/10.1515/dx-2019-0110).
About I3PI: I3PI (http://www.i3pi.com; @I3PI_Inc) has over a decade of experience in building secret shopper programs for healthcare that go beyond customer service to discover and modify practice behaviors that have measurable implications for patient experience, health care outcomes, and costs. For more information about I3PI or this study, please contact Alan Schwartz and Saul Weiner at email@example.com.
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