A National Provider Directory Is Coming. But Will It Help?

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Want to find a provider in your insurance network that takes your insurance? Good luck.

This year, Nadell Ransom, a 36-year-old mom of four in Richland, Washington, received an email saying that her children’s long-time pediatrician was about to retire. While looking for a new doctor, she said, “Insurance is a waste of money. The directory is never right! We called the insurance company, and sure enough, two of the other providers who were listed as taking our insurance were retired. It feels like our healthcare is getting worse and worse. We pay more, but are the doctors taking new patients? No.” Her sentiment was another sign of the declining general trust in medical care nationwide, partly because finding accurate information about affordable care is becoming more difficult.

According to the Centers for Medicare & Medicaid Services (CMS) state Medicaid letter discussed at the ONC National Meeting today interoperability requirements compel insurance programs to maintain a provider directory and update it at least yearly. Perhaps a national provider directory could help fuel interoperability and improve patient trust — but that remains a big what-if.

So, what is a provider directory? Simply put, it is a list of physicians in an area and within an insurance plan. The concept could also include access to other services, such as coordinated care and other services. Physician directories also highlight the misalignment of user needs and design that plagues many electronic health records (EHRs) and other information systems in healthcare.

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Open Provider Directories with Major Errors

Open framework regulations like those released by CMS will be an important step in improving provider directories; payers involved in Medicaid fee for service will be required to share their data through FHIR, which will mean open data for all participants. In theory, this will increase access providers more quickly, meaning patients may select the appropriate health plan.

However, open framework regulations alone do little to address the ongoing problem of physician directories that provide only low-quality data without usable context for most payers, providers and employers. The most recent Medicaid audit of provider directories showed that 52 percent of listings contain inaccuracies. This means an in-network physician may have retired or moved. They also might not participate in your insurance anymore or practice at the location listed. This happens more than half of the time.

Don Lee, an interoperability expert, explained the underlying issues: “The provider directory problem is more challenging than people think. First, we have a data access issue. Everyone maintains their own version of the directory (even within the same organization). Second, we have a data quality issue. The data changes frequently, and there’s no uniform way to broadcast those changes to everyone who needs them. Third, and this is the most important point, we have a context issue. The correct address for billing is not necessarily the correct address for an online provider directory.”

If you have a private practice doctor in a four-physician practice, not every provider will accept every insurance type. One might participate in a local accountable care organization (ACO) and also in Medicaid. One might be involved with a Medicaid ACO and take private insurance. One might practice twice a week and take private insurance. The insurances listed with this practice? All of them. In a larger practice, provider information becomes even more complicated. A doctor might appear to accept a particular insurance online — but a patient may call only to find that this doctor works at one distant location or even retired last year.

Ilana Garon, a 37-year-old Tennessee transplant whose spouse is on active military duty, still maintains her own insurance through work. She had difficulty finding a primary care physician when she moved to Clarksville, a base town 50 miles northwest of Nashville. “I would call one practice to find out that the provider whose credentials I liked only worked in the practice’s Nashville office,” she explained. “Or I’d find out that, though the practice took all insurances, individual physicians didn’t take mine. It’s one of the reasons I stayed on my work’s insurance, rather than switching to Tri-care — it seemed like, overall, I’d be able to see more doctors in more places if I kept Blue Cross Blue Shield. But it was confusing to know where I could be seen.”

Data Quality Improvement

CMS released guidelines about physician directories and how they need to include more data to facilitate access to care earlier this year: “As states and healthcare systems shift focus to value-based payment models, there is also a need to gather and access a more comprehensive set of information about providers.”

In the current system, everyone’s information needs are at odds. Provider directories are a prime example of the misalignment of user needs and design that plagues many EHRs and other information systems in healthcare. Each participant needs a different part of the information: A provider’s billing vendor must find the main address for the entire practice; the provider directory for patient convenience needs to show where the physician practices; the patient wants to see which providers at a certain location accept their plan. This problem is compounded by out-of-date and incorrect information. In Ransom’s case, she called seven pediatricians within her “network” before she found one accepting new patients.

The CMS letter itself mentions that Medicaid patients are especially vulnerable to a lack of care continuity from switching providers, and the national provider directory should account for patients moving between care settings: “States can also consider issues that are prevalent among Medicaid patients, including the issue of Medicaid patients moving often between multiple care settings.”

With the FHIR-enabled connection, we will have better data interoperability than ever before — to data which are, alas, not consistently useful. Addressing the “human problems” of provider directories are the next step toward improving data management and quality after the most recent regulations. States are now required to build a provider directory with Medicaid Information Technology Architecture funds for fee-for-service providers, and points such as provider availability should be included.

National provider directories are a step in the right direction for data interoperability and clarity.

“Provider directories published by state Medicaid agencies can help some Medicaid beneficiaries find out if a provider is accepting new patients, which can help improve access to care.” — CMS, State Medicaid Letter

Improving data quality and state investments in better interoperability will help provider directories become valuable tools that can enable better care delivery to patients nationwide. The correct data infrastructure can benefit Medicaid patients and improve insights about all providers in an area. Existing provider directories are rife with errors, and these regulations will create better continuity. Human data accuracy combined with new regulations will help patients know who their providers are and have better care with more transparency in pricing.

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