Generally speaking, our provider data is a mess. Online provider directories are incomplete and riddled with inaccuracies. Patients can’t find the doctors they need, are misdirected to out-of-network care or simply can’t get a hold of anyone because the contact info is wrong. In a recent Health Affairs study “secret shoppers” posing as patients were able to schedule an appointment with a primary care physician less than 30 percent of the time. Even industry insiders can’t find what they’re looking for. I’ve heard countless stories of providers who were unable to find good, timely referrals for patients with specific needs.

Provider Directories are easy. Right!?

Like many healthcare industry problems, this one seems so simple on the surface. Clearly, it isn’t being made a priority, right? It would seem that the payers don’t care, or the doctors don’t care, or both. Because of that (somewhat incorrect) perspective, payers in particular are coming under fire from consumer groups and the government. Earlier this year CMS announced heavy fines for payers who don’t keep their provider directories up-to-date. Those fines can be as much as $25,000/beneficiary/day for Medicare Advantage plans. Further, plans who don’t comply may be barred from future business and marketing efforts.

Several states are jumping on board with their own laws and California just enacted the stiffest, widest ranging regulation to date. Essentially all plans in California are covered. They must verify that directories are accurate every quarter and make updates to individual provider records within 1-week of receiving new information. California plans will be forced to pay for the difference if a patient is incorrectly directed to an out-of-network provider. With other states mulling their own regulations, payers will soon be looking at multiple layers of rules, fines and other risks. That creates some serious incentive to take action and we’re starting to see the plans moving on it in a serious way.

Provider Directories are not just a payer problem

It’s worth noting that all of these regulations are coming at the problem in an attempt to protect the patient. The idea is to close the gap between having insurance and being able to affordably obtain the care one needs. Solving for patient access is a noble and worthwhile goal, but this is only one way that the bad provider data problem manifests itself.

Provider organizations are struggling with provider directory issues as much as any payer or patient. Within any given hospital you’re likely to find provider directories in multiple systems maintained by multiple departments. Each of them represents a competing version of the truth and is protected by its stakeholders. Their job depends on that data being accurate and they simply don’t trust other teams, even within the same organization, to make changes to the data that could cause them problems. I’ve been told by insiders that they don’t even trust the doctors to provide accurate information. So credentialing maintains a version, HR maintains a version, Quality Assurance has one, operations has another and so on. Each group spends time maintaining their system, asking doctors for updates, paying license fees for the system they’re maintaining it in, and most of them are, by their own admission, doing a pretty bad job of it. This approach yields junk data that becomes the foundation upon which all downstream efforts are built. It leads to all manner of operational issues that arguably cost the U.S healthcare industry billions of dollars annually.

If we can’t get departments within a single organization to collaborate, how are we going to fix this problem on a national scale?

Fixing Provider Directories

The proposed best practices make sense at the 50,000 ft level, but when you start to scale them out across regions, states and the entire country, they get pretty interesting. This post details 5-steps payers can take to make provider directories accurate:

  1. Maintain a single source of truth — All directories should pull from a single database that is curated, verified and kept up-to-date.
  2. They must be able to handle very complex relationships. A single provider might own his own practice, participate in an ACO, have permissions at multiple hospitals, be enrolled in 10–20 insurance plans (some for the ACO and others for his practice), participate in the local HIE with different roles for each organization, etc. It’s a very complex picture and one that changes all of the time.
  3. Enforce workflow — All updates should go through the same channels and verification, stored in a consistent manner (in that single source of truth) and should be regularly checked for accuracy.
  4. Enforce business rules — There are many things we can do to mitigate the risk of bad data entry. For example, there’s a checksum for NPI numbers. That means we can not only make sure they are the right length, but we can ensure that the number entered “might be” a valid NPI. That would take a big bite out of typos. Similarly, we can bounce off of the NPPES database, PECOS database and other publicly available APIs that can help smoke out problems.
  5. Structure data to reduce errors — Eliminate free-text where possible in favor of drop-downs and type-ahead completion lists. This simple step can drastically improve data quality and our ability to make it useful in reporting.

These all sound simple, but I can assure you that in practice they are anything but.

There are many groups attempting to solve this problem right now and their largely taking a collaborative approach, which is the only way we’ll succeed. A few examples:

Each of them is attempting to implement the 5 steps mentioned above to be that single source of quality data for their participating payer organizations. These initiatives show that the industry is taking the problem seriously and collaborating to make it right. However, even if successful they only begin to get us where we need to be. Each participating organization is still responsible for getting this high-quality data from the source into their own operational systems (which are sketchy) and onto their websites so that patients can access it in a meaningful way.

No quick fix

One begins to wonder if this is a problem we should expect to be solved. In other industries, if consumers can’t find the info they need they go elsewhere and the poor data disseminators go out of business. If organizations can’t keep data about their partners up-to-date, it prevents them from working efficiently and again they suffer the consequences. Healthcare doesn’t operate in this same type of consumer-driven environment where things… make sense. Instead, layers of regulation, complex reimbursement schemes, incentives, penalties, etc. create a complex world of competing priorities where it can be very difficult to solve these fundamental issues.

I’m not being a naysayer and I certainly am not suggesting we don’t try. I just want to make sure that we’re thinking about the complexity of the issue and manage our own expectations that this problem won’t be solved overnight and probably not for the next several years.

A journey of a thousand miles…

That said, I’m ecstatic that consumer groups and regulators are casting a spotlight on the issues. It’s already lead to a number of high-powered organizations to dive in and try to take on the problem. If anything, I hope that the pressure continues to mount and we start to look at the operational issues with provider organizations as well. The benefits will be huge if we can get this half right.

The live conversation took place on Firetalk with me and Sahid Shah. We’ll dig into the how and why of the provider data issue. Then we’ll discuss the AHIP Provider Directory Initiative to find out what they’re doing about it and what progress has been made so far.

You can watch the replay here: