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To anyone sitting in the emergency room of the hospital, Barbara Gerber looked like any other patient. She filled out forms, chatted with the triage nurse and plopped down in a chair to wait her turn. A half-hour later, Ms. Gerber was ushered inside and left in the hands of a paramedic. While he examined Ms. Gerber’s throat for the cause of her bad cough, she gave him a thorough looking-over, too. “Apparently, he had just gotten out of an ambulance,” Ms. Gerber said. “His shirt tail was hanging out and there was dirt all over his shoes. You’d expect someone to be dressed in white. His appearance didn’t inspire a lot of confidence.” Minutes later, after receiving a clean bill of health from the soiled, young paramedic, Ms. Gerber drove home, her work having just begun. She then dictated into her tape recorder, noting not only the paramedic’s appearance but how long she had to wait in the emergency room of the hospital, which was in a small Northeastern town. The emergency room receptionist had been friendly, and the desk neat and tidy, she recalled. But on her way to meet the doctor, she was sent down a dark hallway. “I thought, ‘What is going on here?’ “ she said. “ ‘Is this place closed or something?’ That could have been very frightening.” That emergency room may never be the same after her visit. Shortly thereafter, she filed a written report to the hospital. “I’m sure the staff was told to keep the lights on in the hallways after that,” she said. While doctors are used to hearing patients grumble, few complaints carry more weight than Ms. Gerber’s. Rare in the health care industry, Ms. Gerber is a consultant hired by doctors and hospitals to rate their services by posing as a patient. Undercover consumers have long been used by retailers and hotel chains to improve customer service, but they are gaining favor in the health care industry, as more hospitals, health maintenance organizations and doctor’s offices try to improve reputations and attract patients. “These sleuths are keeping the health care providers on their toes,” said Diane Archer, executive director of the Medicare Rights Center, a health care consumer rights group in New York. “We need more of them. And more power to them. They are uncovering important information ‘that helps to promote a more accountable health care marketplace.” Ms. Gerber fell into the profession. Admitted to a hospital six years ago, she was amazed at the attitudes and the services, good and bad. At the time, she was working as a hospital administrator and thought how easily patient service could be improved by listening to patient’s suggestions. As the owner of Devon Hill Associates, a company based in San Diego that conducts health care marketing and sales training, Ms. Gerber soon added mystery’ shopping to her repertoire. Since 1991, she has made undercover visits for 15 long-term care companies and has picked up three hospitals and a doctor’s office as clients in the last three years. VISITS from Ms. Gerber are thorough and expensive. She encourages doctors and hospitals to sign up for one or two inspections to try out the service. One visit costs as little as $400, but the price climbs quickly to $5,000 for a regular inspection, which usually involves three or four visits. Clients who want Ms. Gerber long term, which usually includes monthly inspections at 20 to 30 sites each year, can expect to pay about $60,000 a year. The fee buys an inspection that almost always exposes a few hospital flaws. Three years ago, Ms. Gerber visited Chesapeake General Hospital in Chesapeake, Va., inspecting the mammography clinic as well as longterm care facilities and the gym. “Barbara actually came in and had a mammogram,” said Becky Maples, vice president for planning and marketing at Chesapeake General. “None of the staff complained about being fooled, but in a way Barbara was a real patient.” While Chesapeake’s mammography clinic met with Ms. Gerber’s approval, the hospital’s gym did not. Because the hospital wanted to attract people from the community to exercise, Ms. Gerber was alarmed by what she saw as a lack of enthusiasm among some of the hospital’s sales staff. “Apparently, our sales people would show people around the health facility, and they would be good at giving information but wouldn’t try to close the sale,” Ms. Maples said. “It was something easy to correct, but we may have not known about it had we not had the viewpoint of someone who had actually been through it as a shopper.” Some visits have provided a few surprises. Unstoppable in her critiques, Ms. Gerber once From the front desk to the examining room, Barbara Gerber of Devon Hill Associates in San Diego checks out how patients are treated in health care facilities that hire her. Sometimes she has a routine procedure, like a mammogram, and sometimes she fakes an illness. made it all the way to the operating table to inspect an outpatient surgical unit. She brought the procedure to a halt by telling the surgeon, who was in on the ruse, that she drank orange juice a few hours before, a disqualification for anyone scheduled to receive anesthesia. Afterward, Ms. Gerber dressed and went home, but not before she noted that the surgical staff had behaved professionally. The operating room may appear to be daunting territory, but Ms. Gerber said she has little trouble getting inside. Because Ms. Gerber has an inside contact at the companies that hire her, she can arrange to have procedures bent to allow her to complete her inspection quietly. Usually, the extra hand isn’t necessary. “Sometimes the client may give us a script of what they want us to say to get in,” Ms. Gerber said. “But getting inside the emergency room is relatively easy. People come in there with all kind of complaints that aren’t emergencies. I can say that I have a shoulder injury or a bad cough. They treat me as an outpatient.” On most visits, she wears street clothes, though sometimes she also dons a wig to avoid being recognized. To be fair, Ms. Gerber and two of her employees often visit a site three times before writing a report, taking care each time to note the good with the bad. One emergency room receptionist was written up for repeatedly turning her back while quizzing one of Ms. Gerber’s colleagues about her health history. If the hospital staff cannot make enough mistakes on their own, Ms. Gerber joyously provides some ample opportunities. One of her favorite ploys is to refuse to give her birth date to emergency room registrars, Few hospital employees are willing to accept no for an answer and spend as much as a half hour badgering her for it. “Not giving your birth date can sometimes be a real problem for them,” Ms. Gerber said. “The computer may not print the form out if all the blanks aren’t filled in. it’s interesting to note how upset the hospital staff person gets. The goal is to make the patient feel comfortable, not hound him.” WHILE patient posing may be new to the health care industry, other forms of consumer inspection are also at work. Elizabeth Moore, 75, a retiree from Denver, started shopping last April for a Medicare H.M.O. for herself and her 88-yearold husband, Thornton, and was appalled by what she found. After sending questionnaires to five H.M.O.’s seeking details on their coverage, two refused to respond, and she later discovered that the other three had given inaccurate answers. Roiled, Mrs. Moore became one of the worst enemies of H.M.O.’s in Colorado. To warn the elderly about problems of Medicare H.M.O.’s, she developed her “10 Commandments,” a set of questions that consumers should ask before buying a policy. And she is setting up a Web site (http:// www.healthcare-disclose.com). Last summer, she sent the list to Colorado legislators, who are considering a bill that would require H.M.O.’s to make their policies easily comparable so the elderly can understand them. Mrs. Moore has made her commandments available to anyone in the United States who wants them. As of last week, she had mailed out 320 copies in Colorado alone. “The point is that if you don’t do this kind of shopping, then consumers can’t make good decisions,” Mrs. Moore said. “Some of these facilities don’t want consumers to shop. That’s all the more reason to do it.”
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