Currently Viewing:
The American Journal of Managed Care May 2019
Evaluation of Value-Based Insurance Design for Primary Care
Qinli Ma, PhD; Gosia Sylwestrzak, MA; Manish Oza, MD; Lorraine Garneau; and Andrea R. DeVries, PhD
The Presurgical Episode: An Untapped Opportunity to Improve Value
Erika D. Sears, MD, MS; Rodney A. Hayward, MD; and Eve A. Kerr, MD, MPH
Clarification of References to Medication Adherence Scale
Open Doors to Primary Care Should Add a “Screen” to Reduce Low-Value Care
Betsy Q. Cliff, MS; and A. Mark Fendrick, MD
From the Editorial Board: Daniel B. Wolfson, MHSA
Daniel B. Wolfson, MHSA
Cost-Effectiveness of DPP-4 Inhibitor and SGLT2 Inhibitor Combination Therapy for Type 2 Diabetes
Manjiri Pawaskar, PhD; S. Pinar Bilir, MS; Stacey Kowal, MS; Claudio Gonzalez, MD; Swapnil Rajpathak, MD; and Glenn Davies, DrPH
Currently Reading
Improving Provider Directory Accuracy: Can Machine-Readable Directories Help?
Michael Adelberg, MA, MPP; Austin Frakt, PhD; Daniel Polsky, PhD; and Michelle Kitchman Strollo, DrPH, MHS
Potential Impact of Pharmaceutical Industry Rebates on Medication Adherence
Leah L. Zullig, PhD; Bradi B. Granger, PhD; Helene Vilme, DrPH; Megan M. Oakes, MPA; and Hayden B. Bosworth, PhD
Producing Comparable Cost and Quality Results From All-Payer Claims Databases
Maria de Jesus Diaz-Perez, PhD; Rita Hanover, PhD; Emilie Sites, MPH; Doug Rupp, BS; Jim Courtemanche, MS; and Emily Levi, MPH
Beyond Satisfaction Scores: Exploring Emotionally Adverse Patient Experiences
Laura M. Holdsworth, PhD; Dani L. Zionts, MScPH; Karen Marie De Sola-Smith, PhD; Melissa Valentine, PhD; Marcy D. Winget, PhD; and Steven M. Asch, MD
Patient-Centered Medical Homes and Preventive Service Use
Joel F. Farley, PhD; Arun Kumar, PharmD, MS; Benjamin Y. Urick, PharmD, PhD; and Marisa E. Domino, PhD
Pilot of Urgent Care Center Evaluation for Acute Coronary Syndrome
Ryan P. Radecki, MD, MS; Kevin F. Foley, PhD; Timothy S. Elzinga, MD; Cynthia P. Horak, MD; Thomas E. Gant, MS; Heather M. Papp, BA; Adam J. Morris, BS; Natalie R. Hauser, BA; and Briar L. Ertz-Berger, MD, MPH

Improving Provider Directory Accuracy: Can Machine-Readable Directories Help?

Michael Adelberg, MA, MPP; Austin Frakt, PhD; Daniel Polsky, PhD; and Michelle Kitchman Strollo, DrPH, MHS
The authors examined the accuracy of provider directories and found widespread errors. Machine-readable directories are not more accurate than conventional directories, despite their advantages. A survey of promising initiatives to improve directory accuracy was also completed.
ABSTRACT

Objectives: To examine inaccuracies in health plan provider directories and consider whether the machine-readable (MR) formats required of provider directories in the health insurance exchanges are more accurate than conventional directories and have the potential to improve directory accuracy in the future.

Study Design: The descriptive study design included qualitative data collection through stakeholder interviews and quantitative data analysis and verification of provider data source accuracy from multiple sources.

Methods: Four separate sources of provider data from 5 counties were captured and aggregated into an analytic database. Provider data were analyzed through text matching techniques and provider practice phone interviews. Additionally, we interviewed 21 stakeholders.

Results: In quantitative analysis, we found widespread inaccuracy in provider information across directory types. Provider directory phone numbers were more likely to align with Google data than with the directory for the same company’s health plans in other markets. It is vastly less expensive to aggregate data from MR files than from conventional directories, which suggests that MR files have potential to be cost-effectively leveraged for data quality improvements. In qualitative analysis, we found that interviewees perceived provider directories as inaccurate, but they differed in their perceptions of the severity of the problem. Interviewees who were familiar with MR directories understood their advantages over conventional directories.

Conclusions: The MR provider directories are not more accurate than the conventional provider directories. However, there is strong reason to believe that MR technology can be leveraged to increase accuracy. Promising state- and vendor-led initiatives also have the potential to correct widespread provider directory inaccuracy.

Am J Manag Care. 2019;25(5):241-245
Takeaway Points

Provider directories are widely inaccurate. Conventional Medicare Advantage directories are currently slightly more accurate than machine-readable (MR) health insurance exchange directories, and Google is more accurate than either directory type. Although MR directories are not more accurate than conventional directories, they can be leveraged to improve directory accuracy. However, this has not yet occurred.
  • The problems with provider information are more complex than the problems specific to directories.
  • Promising state- and vendor-led initiatives are underway and deserve further attention.
  • Without accurate provider information, plan members cannot navigate their plans successfully, regulators cannot ensure plans meet requirements, and researchers have no accurate source of provider information.
Enrollees in managed care plans expect reasonable access to healthcare providers, yet “reasonable access”—a standard mandated by the Affordable Care Act—is a vague term never defined in federal regulation. Regulators measure access differently, from national standards in Medicare Advantage (MA) plans to individualistic network access plans in several states. Once a provider network is judged adequate by the regulator, the plan’s provider directory is the document that enrollees use to find providers. However, information in provider directories is often incorrect. There are 3 types of errors: a listed “in-network” provider has errant information, a provider listed as in network is not, and a provider that is in network is omitted.

A recent report from CMS found that 52% of providers in MA provider directories included at least 1 inaccuracy.1 This MA error rate is consistent with those in exchange and California Medicaid directories.2 In the last few years, significant regulatory actions have been taken against a handful of health plans with patterns of inaccurate provider information. In the last year, lawsuits were filed against 3 health plans by consumers who allege that they selected their health plan based on false provider network information.3-7

Health plans struggle with provider network accuracy for a number of reasons. Providers are frequently indifferent to keeping directories current: The unglamorous task of notifying health plans of changes is often delegated to junior office staff or no one at all. The patchwork of regulatory definitions and standards for directories is another problem. Although some promising state- and vendor-led initiatives are now underway (see eAppendix A [eAppendices available at ajmc.com]), regulators are uncoordinated on definitions, requirements, and oversight approaches.

Machine-Readable Provider Directories

Provider directories are commonly posted on the internet in PDF or other “flat file” formats that defy easy downloading, aggregation, or analysis. In 2013, the state of California began requiring machine-readable (MR) health information. A number of newly established state-run health insurance exchanges required the use of MR provider directories in 2014, and CMS picked up the requirement for the federally facilitated exchanges in 2016.8,9 By requiring health plans to post their provider directories in a common MR format, directories can be easily downloaded to assess network adequacy against regulatory standards or network breadth among competing plans. In addition, MR directories can also populate physician finder consumer tools and improve provider data accuracy by flagging cases in which a provider is inconsistently listed across data sources. Here, we present data on the accuracy of MR directories in comparison with other sources of provider information.

METHODS

The study was conducted using quantitative and qualitative analyses. Data were collected and analyzed through quantitative research to compare accuracy among MR provider directories on the exchanges, traditional flat file provider directories in MA plans, and additional sources of provider information. Interviews were simultaneously conducted with relevant federal and state officials and key industry stakeholders to capture their knowledge of and experience using both types of provider directories. This study did not require institutional review board review and approval.

Quantitative Analysis

Quantitative research questions. Our quantitative research questions were (1) “How do electronically available data sources vary? Are the same data reported across sources?” and (2) “How consistent are the provider data found in electronic sources with information gathered from phone validations conducted with provider offices?”

A secondary research question (“What are the differences in level of effort [time and cost] to aggregate MR files versus other data types to conduct analyses of provider networks?”) is discussed in eAppendix B.

Sampling methodology. We selected 5 US counties across the country with insurance carriers that offer both MA and exchange health plans. We selected these counties based on geography, market penetration, and the presence of an insurer serving both the MA and exchange markets.


 
Copyright AJMC 2006-2019 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
x
Welcome the the new and improved AJMC.com, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up