Provider directories are still ‘shockingly’ inaccurate, California study finds

Published on
July 14, 2016

Imagine the scenario: A newly insured patient looks up primary care physicians for his first appointment, eager to find care somewhere other than the emergency room. But the phone number listed in his insurance directory doesn’t work. The next doctor he tries doesn’t work at that office anymore, and the next primary care provider turns out to be a gastrointestinal surgeon.

“You might be willing to call another, and another, but eventually you’re going to feel like your insurance is useless and end up in the ER,” said Simon Haeder, an assistant professor of political science at West Virginia University, who recently conducted research on provider directories. “It’s certainly not the way you would hope insurance would work.”

That situation, though, happened in a “shocking” 70 percent of the times Haeder’s team of “secret shoppers” tried to make an appointment with 743 primary care providers listed in California health insurance directories. The inability to schedule appointments was largely a result of inaccurate and outdated provider information as well as doctors’ resistance to taking new patients, he explained in a recently published Health Affairs piece he wrote with David Weimer and Dana Mukamel. 

To improve access, researchers stressed the need for insurers to update their directories more frequently, with clear incentives or penalties for both providers and insurers who fail to provide accurate information. California is leading the way on those efforts with new legislation aimed at improving provider directories that went into effect this month.

Still, the latest research raises troubling concerns about patient access, especially to primary care providers, as well as the burden “our fragmented system puts on patients to coordinate their own care,” a struggle recently described by reporter Sarah Kliff in this Vox piece. This latest study also adds an interesting caveat to the discussion on narrow networks.

“More and more people are talking about network adequacy,” Haeder said, referring to the number and type of doctors included in a given insurance plan. “But we don’t know what the networks look like right now because the numbers are so inadequate.”

Unexpected findings

In most cases, researchers found that providers accepted equally people who had obtained insurance plans through Covered California or the private market. However, Haeder cautioned that the sample size for this finding was small, since it was so hard to get through to a provider in the first place.

“We expected to find a larger difference between plans on and off the exchange,” he said. “In both cases, it was very unlikely to get an appointment.”

Overall, the “secret shopper” patients were only able to schedule appointments in 29 percent of cases for plans sold outside of Covered California, and 27 percent of cases sold on Covered California. Only about 10 percent of the access problems arose because the provider wasn’t accepting new patients. More often, providers didn’t work at the location, they had the wrong specialty listed or they couldn’t be reached at all.

It’s striking that you’re listed in provider directories and, all of a sudden, you tell someone, often with limited financial resources, that it’s an additional $2,000 to get into their practices.  Simon Haeder, West Virginia University

When providers could be reached, it took on average 23 days to schedule an appointment for a routine condition or physical, and 12 days for an acute need, such as having a high fever, stomach problems and muscle pain. Wait times were slightly lower if shoppers were willing to see another provider.

An unexpected finding of the study was that some practices charged patients additional fees, separate from insurance, to see a provider. In a handful of cases, a new patient’s insurance was accepted but the office tacked on a “membership fee” of $2,000 a year to be part of the group.

“It’s striking that you’re listed in provider directories and, all of a sudden, you tell someone, often with limited financial resources, that it’s an additional $2,000 to get into their practices,” Haeder said. 

Researchers chose California in part since the five distinct regions chosen – North, Inland Empire, Central Valley, San Francisco and San Diego – might have findings applicable to different parts of the country. In California’s rural north, for example, it was easier to reach the right provider, but still very hard to get an appointment, underscoring the “startling provider shortages in rural areas.”

Addressing the issue

Across the country, there have been few incentives for providers and insurers to maintain updated directories, Haeder said. In fact, there are some disincentives to pruning bad information, since more robust directories can make insurance networks appear larger and more attractive to consumers, he added. On the physician side, they also have much incentive to spend staff resources updating their information. Regulators also struggle with the manpower to check accuracy. And consumers often don’t have the time or knowledge to report concerns.

The magazine Healthcare Finance recently unpacked some of the complexities inherent in organizing directories. While it may appear a simple task, there’s a lot of reasons behind the errors, explained Louis Kolssak, vice president of network management at McKesson Health Solutions.

All too often, a record is corrected in one database but not another, Kolssak said. Or, because of faulty data processes, the newer corrected data record keeps getting overwritten with outdated information. Secondly, often there is no one owning the process for updating and correcting directory entries. Third, physicians who work out of multiple facilities sometimes need to be listed in different networks for each location. The net result is a web of interconnected relationships that most systems can't handle without massive manual entries, Kolssak said.

One strategy for improving directories is to fine insurers with inaccurate directories, or to allow insurers to withhold physician payments if they don’t respond to updating inquiries.

“People are frustrated,” Haeder said. “We’re just at the beginning of where states are addressing this issue.”

Nationally, CMS has tightened provider directory rules. But some of the biggest steps have been taken in California.

In 2015, California’s Department of Managed Health Care fined Blue Shield and Anthem for unacceptable inaccuracies in their provider directories, and instructed them to improve directories. Insurance companies insist they’re working on fixing the problem. Last week, industry representatives told reporter Emily Bazar of Kaiser Health News that they’re spending millions and dedicating significant manpower to ensure more accurate directories.

Another opportunity for improvement has come from health care consolidation. As a condition of merging, entities can be required to invest in technology that could improve the accuracy of provider data, said Anthony Wright of Health Access California, a consumer advocacy group.

But perhaps the most notable step is SB 137, a new California law that went into effect his month, which requires insurers to update their online directories once a week and their printed ones every quarter. That requirement is stricter than federal requirements, said Betsy Imholz, the director of special projects for Consumers Union. That law, and the penalties that come with it for both providers and insurers, could be a model for the rest of the country: “We are really leading the way,” she said.

“We’re glad there is a solution … in the works, though obviously there is much more to do to make this real for consumers,” Wright said. “What the bill does is set the standard for the expectation. Now it’s up to insurers to actually implement it and regulators to hold them to it.”