The secret shopper methodology is exceptionally relevant to family medicine. Serving as the ideal mechanism of preventative healthcare—which at its core has the aims to provide equitable care to all—family medicine represents an ideal opportunity to improve healthcare delivery, elevate the patient experience, and reduce disparities in access. The methodology outlined here can be used to ascertain areas of potential improvement within the healthcare cascade [17, 18].
It is challenging to objectively measure patients’ ability to access healthcare. When surveyed about appointment availability, physicians’ offices tend to overestimate their capacity to accept hypothetical new patients . Patient and physician surveys often fail to accurately capture biases—particularly those related to sensitive or stigmatized topics—which may impact patients’ experiences with healthcare providers and, consequently, their access to appropriate care . Furthermore, physicians’ offices may not be forthcoming about their health insurance policies, especially when discussing their ability or willingness to promptly accept Medicaid patients . Each of these elements is integral to providing good care in family medicine.
The secret shopper methodology serves as an objective measure for studies seeking to evaluate patient access to care . This method is particularly useful in overcoming the “Hawthorne effect” in situations similar to the one described above, in which providers’ behaviors or policies might change if they were aware that they were being observed . For example, an audit of orthopedic surgery practices to evaluate patient access to knee and primary and revision arthroplasty found that orthopedic surgeons’ offices responded differently to a faxed survey about Medicaid acceptance policies than they did to a simulated Medicaid patient calling and attempting to schedule an appointment . A study examining delays to emergent surgical care revealed discrepancies in emergency department referrals based on insurance status . These results suggest that practice policies and staff behavior may not be accurately captured in a survey.
Insurance-based discrepancies in access to care impact the healthcare system in a variety of ways. Understanding shifts in the burden of healthcare service utilization can reveal gaps between policy and practice. Accordingly, the United States Department of Health and Human Services recommends using secret shoppers to measure healthcare access . A 1994 study by the Medicaid Access Study Group employed this methodology and found that Medicaid patients were less able to access timely medical appointments, a finding that contributed to the explanation for that population’s increased use of emergency departments for nonurgent issues . Other secret shopper studies have revealed insurance-related disparities in access to primary [8, 18, 26–28], follow-up , orthopedic , dermatologic , pediatric [31, 32], newborn , reproductive , and psychiatric  care, among others . In addition to highlighting challenges associated with insurance, secret shopper studies can assess administrative staff’s knowledge of details related to coverage, such as the likelihood of receiving a surprise bill or the availability of alternative payment options [36, 37].
Furthermore, simulated patients can obtain more detailed information about the intricacies of patients’ experiences within a complex and evolving healthcare system. The last decade has seen substantial increases in vertical and horizontal consolidation of health organizations and medical practices [38, 39]. These consolidations have affected all sectors, but particularly family medicine. To cite a few downstream effects: increased costs, increased travel time for patients, and no improvement in quality of care . These mergers are often associated with higher prices and spending, and budgeting decisions inevitably affect reimbursement, clinical decision making, local competition, referrals, and patient experiences [41–43]. These nuances impact access to care but might not be apparent on practice websites or in healthcare policy. For example, in addition to determining appointment availability based on insurance type, secret shopper studies can probe for information about how patients are treated by providers or staff based on their insurance. Secret shoppers may also identify additional barriers to receiving care, such as referral requirements, long wait times before obtaining appointments, and the requirement to send records and obtain testing results prior to the visit, which might not be expected of patients with private insurance .
These findings are especially useful for evaluating access to care in a period following Medicaid expansion and the COVID-19 pandemic in the United States, when policymakers, providers, and patients alike seek to understand whether health insurance coverage alleviates differences in healthcare access to the underinsured. Secret shopper studies are well-positioned to expose these disparities and provide insight into how patients navigate the healthcare system .