It’s no secret better health care depends on improving quality, affordability and the experience a patient has with the healthcare system. But how the health care system achieves these goals may surprise you: “secret shoppers.”

For the past two years, Horizon Blue Cross Blue Shield of New Jersey and its physician and research partners have used “secret shoppers” to evaluate the care that doctors throughout New Jersey are providing their patients.

These shoppers, also known as “unannounced standardized patients (USPs),” are trained actors who appear to be real patients to doctors. Their visit is recorded and then reviewed along with the doctor’s notes from the patient’s medical record by a team of researchers. The findings are reported back to the doctor along with suggestions that can help the doctor improve care. Doctors choose to participate, but have no idea when they are treating a USP in their office.

Long used to evaluate customer service in restaurants, hotels and retail settings the use of secret shoppers to directly observe health care is relatively new. But it’s vital to improving quality.

“Today measuring quality means looking at what doctors put in a chart or what patients put on a patient satisfaction instrument,” said Saul Weiner, MD, co-founder of the Institute for Practice and Provider Performance Improvement (I3PI), who helped lead this project. “Even though we're spending trillions of dollars on healthcare in this country, nobody's observing it. It's kind of a black box when the doctor walks into the exam room.”

Unlocking that black box through this program helped doctors improve the quality of care provided to patients and by extension lower the overall costs of care.

Secret shopper research is a team effort

This project, supported by a grant from the Robert Wood Johnson Foundation, represents the first time a large health insurer has used USPs to help physicians evaluate and improve care.

Horizon and the I3PI team worked together to focus on the health conditions contributing to rising healthcare costs, including diabetes, cancer care, pain management and depression. Horizon then identified physician practices involved in its value-based health programs to offer them the chance to participate.

Trained actors ensured all doctors had a similar interaction with patients. “If we want to measure depression, we can train a ‘patient’ to screen positive on a depression test. If we want to measure diabetes care, we can train the patient to see if their feet are examined,” said Dr. Weiner.

For each health condition, the team developed a list of behaviors, based on evidence-based standards, that they expected the doctors to perform.

The project also measured how doctors “contextualize care.” Doctors need to look out for the real-life challenges their patients are facing, such as their ability to afford their diabetes medicines.

“When doctors miss issues relating to their patients’ life context, such as their access to care or ability to afford care, those errors can be more costly than simple medical errors,” said Dr. Weiner.

Better performance, lower costs

Doctors in the study saw four USPs – two before receiving feedback and two after. Study results showed:

Improved adherence to evidence-based practices post-USP intervention across most of the six areas studied.

• Evidence of a reduction in the misuse and overuse of medical services and, in select areas, addressing underuse (e.g. increasing referral for chronic back pain to physical therapy).
• Participating physician practices realized savings of $8,000 a month compared with practices not involved in the study. These savings represent fewer health insurance claims submitted on behalf of the practices’ patients.

Despite overall cost savings, there were some areas where costs increased, but this isn’t exactly a bad thing, explained Alan Schwartz, PhD, co-founder of I3PI.

“Sometimes higher costs can be helpful. For example, with back pain, it costs more to send patients to physical therapy rather than prescribing them morphine,” said Dr. Schwartz. “In the long run, we’d expect overall costs to go down because the patient would be healthier.”

Giving doctors the opportunity to improve

Participating doctors were granted 20 hours of Maintenance of Certification (MOC) Credit from the American Board of Internal Medicine and the American Board of Family Medicine and doctors were assured study findings wouldn’t be held against them. “We told the physicians, ‘We're never going to embarrass you. This data will be shared only with you. See this as an opportunity to learn from almost looking in a mirror,’" said Dr. Weiner.

Indeed, most doctors participated because they wanted to improve. Take, for example, Stephanie Doyle, MD, a primary care provider with Cape Regional Health System in Rio Grande. “I wanted to know what I did and didn’t do so well,” said Dr. Doyle. “Not since medical school has patient care been directly observed. As soon as you get out of residency, you’re on your own.”

These sentiments were echoed by Douglas Ashinsky, MD, an internist with RWJBarnabas Health in Warren. In practice for 30 years, this experience was new for him. “Medicine is about constantly learning and about constantly changing your behavior to improve the care you give. The ultimate benefit is better patient care: hearing about what I do and adjusting what I do to create a better experience for the patient,” said Dr. Ashinsky.

Making more of an impact

Dr. Weiner would like to expand this program to more places and more practices. That’s because the project has shown a new way forward on making value-based care a reality.

“Ten to 15 years ago, there was the belief there had to be a huge tradeoff in terms of cost and quality in health care,” said Dr. Weiner. “Value-based care seeks to improve quality and lower costs. And our study shows that the way to do that is by providing just the right care.”

Getting to these results required a new way of thinking – not just from doctors and researchers but from health insurers like Horizon.

“It's not always easy to find a partner for cutting-edge work,” said Dr. Weiner. “Horizon has shown this commitment to trying out new things to make care better.”