For many Americans, accessing health care can be deeply frustrating, stressful, and confusing. While individuals may face various problems when navigating insurance and the health care system at-large, the initial task of scheduling an appointment with an in-network provider should arguably be the most straightforward. However, according to a 2023 KFF survey, a quarter of insured adults experienced a time in the past year when an in-network provider they needed to see did not have available appointments. When looking at Medicaid specifically, 33% reported this issue. This is despite the fact that 39 states and D.C. have appointment wait time standards in their Medicaid managed care programs to ensure that enrollees receive care from in-network providers within reasonable timeframes.
Medicaid enrollees face large gaps in access to care, including long appointment wait times, persistent provider directory inaccuracy, and ghost networks. Moreover, the barriers and costs of navigating American health care are only compounded for those most marginalized in our society: Black, Indigenous and other people of color, LGBTQI+ individuals, people with disabilities, people with limited English proficiency, people living in rural areas, and those sitting at the intersection of multiple identities experience additional disparities in timely access to care.
The recently finalized Managed Care Access rule seeks to make plans more accountable for these network adequacy issues in part by requiring states to contract with independent entities to conduct annual secret shopper surveys. Secret shopper surveys are a research methodology where “secret shopper” callers, who do not identify themselves as evaluators, pose as enrollees trying to schedule an appointment with a provider. By putting the evaluator directly into the enrollee’s shoes, these surveys produce credible, unbiased, and actionable data that reflect the true experience of an enrollee trying to schedule an appointment.
The newly required independent secret shopper surveys would directly test managed care plan compliance with the new federal appointment wait time standards as well as help validate provider directory accuracy. These surveys would verify four critical elements of provider information: (1) active network status, (2) street address, (3) telephone number, and (4) whether they are accepting new Medicaid enrollees. CMS is requiring that these surveys be conducted for the three provider types for which federal appointment wait time standards have been established (primary care, OB/GYN, and outpatient mental health and substance use disorder) in addition to a fourth state-chosen provider type. States must receive information on all provider directory data errors identified in secret shopper surveys no later than three business days from identification and must then send that data to the applicable managed care plan within three business days of receipt. The secret shopper survey results must also be annually reported to CMS and publicly posted on state websites, enabling enrollees, advocates, and providers to track plan performance and hold them accountable.
Many states already have experience with implementing secret shopper surveys within their existing external quality review (EQR) processes. According to a 2022 KFF survey, 28 states use secret shopper surveys to monitor managed care plan compliance with network adequacy standards and access requirements. States like Texas, Maryland, Connecticut, Missouri, New Hampshire, and Ohio have identified massive error rates in provider directories and long appointment wait times through mechanisms like secret shopper surveys. For example, Maryland’s extensive survey of online and paper provider directories led to nine corrective action plans for managed care organizations (MCOs) in 2019. Texas’ external quality review organization (EQRO) study, which only successfully contacted 52% of providers in 2018, includes a list of best practices for more accurate provider directories.
Because many states already have prior experience conducting secret shopper surveys, the 2028 effective date in the final rule is disappointingly slow. Due to the known persistence of error-ridden provider directories, these newly required secret shopper surveys must be accompanied by carefully thought-out plans for enforcement. States may be able to receive an enhanced 75% federal match for conducting secret shopper surveys as an optional EQR activity, making a robust survey design more affordable. While there are certain limitations with secret shopper survey design, including instances in which providers may not schedule appointments without proof of identity, prior studies comparing secret shopper against revealed caller surveys demonstrated the value of anonymous direct testing. It is not always clear that posting better results from a revealed caller survey stems from an inability to complete the appointment process or from providers accommodating a request from a known evaluator.
Overall, secret shopper surveys are a truly valuable tool for states to directly test and improve Medicaid managed care enrollees’ access to care. The surveys will be essential to enforcing the 90% compliance rate with the new federal appointment wait time standards, in addition to assessing and improving provider directory accuracy and general network adequacy. States can also go further and leverage their secret shopper surveys to test additional specialty provider types and identify access barriers and inequities for marginalized groups. For example, secret shopper surveys can be designed to gather information on physical accessibility, language access, and discrimination and disparities on the basis of various demographic characteristics. Connecticut has previously incorporated design elements like Spanish-speaking callers and callers identifying with multicultural names in its secret shopper surveys. In this way, secret shopper surveys may prove to be powerful tools not only in monitoring and enforcing network adequacy, but also in measuring and advancing health equity.
