In a new Health Affairs Scholar article, Haeder and Zhu conduct a follow-up study on Pennsylvania insurance directories on the entries that they had identified as being wrong in their first study. The short version of the results is that bad data sticks around for a long time:
We re-surveyed inaccurately listed Pennsylvania providers (n = 5170) between 117 to 280 days after a previous secret-shopper survey. Overall, 19.0% (n = 983) of provider directory listings that had been identified as inaccurate were subsequently removed, 44.8% (n = 2316) of provider listings continued to show at least 1 inaccuracy, and 11.6% (n = 600) were accurate at follow-up. We were unable to reach 24.6% (n = 1271) of providers.
Why does this matter?
Currently, we regulate networks on the basis of their directories. We assume that the data is good and that it accurately-ish represents reality in the very recent pass. However, we know that the data is seldom good. The types of errors range widely from office hours being wrong (an error might be the directory listing hours from 9:00-6:00pm when it is really 9:00 to 5:00) or a doctor not working at an address any more as they completed their fellowship and are now three states over to the office not accepting a particular insurance at all or accepting new patients with that insurance.
Insurers have an obligation to update and correct their directories. Speaking as someone who was responsible for the UPMC Health Plan provider file from 2011-2014, that is an extremely difficult task. When I was working that task, directories were neither a profit center or a heavily regulated activity. We did our best but there was minimal competitive advantage to having a pristine directory. Newer regulations have put some teeth and cash incentives to having better directories but those are not huge.
Haeder and Zhu are showing that these incentives aren’t strong. Less than 1 in 8 identified errors were confirmed to be updated after they were identified. I would bet that if they resurveyed the good locations from their previous study, there would be a decent number of new errors. Data only stays good for short periods of time unless very substantial and expensive efforts are made to keep the data good.
As long as we rely on directory based network adequacy standards, insurers will have incentives to be optimistic about their reported networks. The Centers for Medicare and Medicaid Services is proposing to move towards wait time network adequacy standards. That approach will change insurer network directory maintenance incentives to more accurately reflect who is actually able to take patients. I think that might help a little bit.
* Why yes, I am in that weird liminal space between submitting my dissertation and defending it. More details tomorrow!
Steeplejack
Typo in headline: it’s persistent, not persistant.
CaseyL
Directory updates can be a pure PITA. Ask me how I know…
“Who is responsible for collecting the information and making sure it’s disseminated? ” – not as straightforward as it should be.
Vital information, like what forms of insurance are accepted, and which providers are accepting new patients with Medicare, can be damned hard to track down. Just calling the clinic and asking is probably the best way, but even that assumes the people answering the phone have the latest information.
Going by what the website says… also assumes the website is up to date. And who is responsible for that?
I feel for whoever has the job. I work for a major medical center, one that does teaching and research as well as patient care, and if I had to get information about a different department than mine, I would have only the vaguest idea who to call. What normally happens is, I call whoever I can find, and they say I need to talk to another person, so I call that person, and the hunt may go on from there.
PAM Dirac
If I were dictator of the universe I would require this statement to be the first paragraph of any effort to extoll the virtues of the latest, greatest data analysis “solution”. Maybe even have it tattoed on the forehead of anyone giving a talk about these “solutions”. It might get at least a fraction of the potential consumers of these miracles of data science to ask if the data relevant to their particular use meets this criterion. Yes this comes out of bitter experience, but since I’ve been retired for a few years I think I will not risk resurrecting those demons by ranting further.
Hazmat
As a provider, insurance companies make it difficult to impossible for me to update practice information in their directories, with multiple calls and faxes resulting in no change, or updated information reflected in one department but not in another.
Thanks as always for all your work, David! We knew you when!
tokyocali (formerly tokyo ex-pat)
Best of luck on the dissertation defense. It has been a pleasure to watch you develop as an authority in healthcare. I started an Ed.D. last year. I am enjoying the study but the prospect of data collection is daunting. As you point out, data can have a shelf life.
David Anderson
Good luck and e-mail me if you want a peer to share mid-life grad studenting experiences
Barbara
A big issue is that most contracts can be terminated on short notice by either party, and there is a constant flux of activity during the course of the year. Some plans try to avoid this by limiting termination to the end of the period, so guaranteeing at least some continuity throughout a 12-month period. Add to that that providers themselves (especially physicians) move around so even if a group is in the network, your doctor might have moved, and typically, it would be the group’s role to inform a plan when that happens. There is just a lot more churn than you would think.
Jeanne Fisk
As a behavioral health provider who so wants to continue to take insurance, insurance companies do not make it easy. Making changes to demographics is a nightmare. I changed my office three years ago, still getting clients sent to old address. Except for medicaid. I will take medicaid forever. I have a direct person who I can contact for anything and they resolve it for me. End rant
Lexisaurus
Have any states tried regulating directory accuracy to change those incentives? I suppose there might be a pre-emption problem for ERISA plans, but it seems like Medicaid ACOs and state insurance exchange plans might be within reach?
Yutsano
I just had a weird variation on this. I called the provider to schedule my first appointment and the scheduler asked, “We have three providers accepting new patients. Which one would you like to see?” It took all I had to say, “Lady, I know exactly boo about your office!” so I asked her who was good and she couldn’t even answer that. So I took the first name she suggested. What happens from here? Who knows?
jimbales
David
Best
Jim
Ian R
As someone who spent several hours yesterday trying to find a new doctor, I really feel this.
Sort insurance company provider list by “accepting new patients”, go to websites of physicians to find that absolutely none of them are actually accepting new patients, except the ones accepting only patients for some of their listed specialties. (I don’t not need a gastroenterologist, but why did BCBS’s website suggest him as a PCP?)