Some of the nation’s strictest provider network regulations have led to neither high rates of provider directory accuracy nor timely access to mental health care.
Objectives: To evaluate the accuracy of provider directories for mental health providers and network adequacy, defined as timely access to urgent and general care appointments in California.
Study Design: We assessed provider directory accuracy and timely access using a novel, comprehensive, and representative data set of mental health providers for all plans regulated by the California Department of Managed Health Care with 1,146,954 observations (480,013 for 2018 and 666,941 for 2019).
Methods: We used descriptive statistics to assess provider directory accuracy and network adequacy assessed via access to timely appointments. We used t tests to make comparison across markets.
Results: We found that mental health provider directories are highly inaccurate. Commercial plans were consistently more accurate than both Covered California marketplace and Medi-Cal plans. Moreover, plans were highly limited in providing timely access to urgent care and general appointments, although Medi-Cal plans outperformed plans from both other markets when it came to timely access.
Conclusions: These findings are concerning from both the consumer and regulatory perspectives and provide further evidence of the tremendous challenge that consumers face in accessing mental health care. Although California’s laws and regulations are some of the strongest in the country, they are still falling short, indicating the need to further expand efforts to protect consumers.
Am J Manag Care. 2023;29(2):96-102. https://doi.org/10.37765/ajmc.2023.89318
Mental health services have long been an afterthought in the US health care system, with lack of care compounding the stigmatization and exclusion that individuals struggling with mental health issues face.1-3 It is established that lack of access to these services may impose significant individual and societal costs.4 However, although a variety of statutory changes in the past 2 decades has expanded mental health coverage requirements, consumer access to mental health services remains limited,1,2,5,6 a situation that has only been exacerbated by the COVID-19 pandemic.7,8 Highlighting the lack of access, consumers are substantially more likely to see an out-of-network provider for mental health care than for other types of care.9-11 Yet, 2 potential barriers to accessing mental health care—the interlinked issues of inaccurate provider directories and inadequate provider networks—remain underassessed.4,12
Given the vital role that provider directories and provider networks play in connecting consumers to care, inaccurate provider directories and inadequate provider networks may potentially harm both the health and the financial well-being of consumers. Most obviously, there is the time-intensive administrative burden of combing through faulty directory entries and calling offices to find in-network doctors.13 But even more concerningly, the inability to locate an accessible in-network provider may lead to delayed or foregone care.4,14,15 Directory errors and inadequate networks also impose financial risks to consumers when consumers knowingly seek care outside of their network because there is not adequate access to in-network care.11,16-19 Evidence also suggests that these burdens disproportionately affect disadvantaged populations.20,21 Finally, directory errors raise systemic concerns about the efficacy of health care regulation because regulators extensively rely on directory data for regulatory assessments of networks.4,22
Concerns about inaccurate provider directories and inadequate provider networks have sparked limited policy responses at both the state and federal levels.4,23-25 The federal government has directory accuracy regulations in place for Medicare Advantage, Medicaid, and marketplace plans, and a federal law governing directory accuracy for all other plans came into effect in 2022.26 In addition, a minority of states have taken some action to improve directory accuracy, and slightly more than half of all states have put in place quantitative network adequacy standards.11,24,27 Overlapping policies specific to directories and networks are state and federal parity laws that aim to ensure adequate coverage of and access to mental health care.28
Although scholars have begun to pinpoint directory errors and timely access to appointments as key barriers to health care, most of what we know about provider directory accuracy and timely access is based on a small “secret shopper” survey conducted at a single point in time.11,29-31 The present analysis overcomes these limitations by making use of annual reports that nearly all plans regulated by the California Department of Managed Health Care (DMHC) must submit. These data allow us to comprehensively assess (1) how accurate mental health provider directories are and (2) whether consumers can schedule appointments promptly. The present analyses add to a growing literature22,32,33 suggesting that current legislation and regulation have failed to offer substantial protection for consumers seeking mental health care.34,35
METHODS AND DATA
California has been a leader when it comes to regulating provider networks.26 Indeed, the state was one of the first to adopt a directory accuracy law.36,37 The law, which has been highlighted as a model for other states to adopt, governs both Medicaid managed care organizations (referred to as Medi-Cal in California) and commercial plans.38 All California carriers must issue accurate provider directories in print at least quarterly, update online directories at least weekly if corrections are warranted,39 and also fully verify their directories at least once a year. Regarding network adequacy, under California’s “timely access” standards,40,41 health plans must provide consumers with urgent care appointments for psychiatrists and other nonphysician mental health providers (NPMHPs) within 96 hours and with general appointments within 10 days for NPMHPs and within 15 days for psychiatrists.40,41 “Nonphysician mental health provider” is the catch-all category prescribed by the DMHC that covers a diverse set of providers ranging from qualified psychologists to autism services professionals to alcohol counselors.
The DMHC, responsible for 93% of the California health insurance market, extensively regulates provider directory accuracy and network adequacy. To assess compliance, the DMHC requires all carriers to annually survey their entire network, strictly following a standard method developed by the DMHC to provide “statistically reliable and comparable results across all plans.”41 From 2010 until 2016, the DMHC allowed for a variety of methods to assess compliance.37 Standardization was implemented in 2016, with multiple refinements over the years.37 The surveys are based on carriers’ directories and rely on a multimethod approach to assessing accuracy and timely access that includes, for example, contacts via email and up to 2 phone calls. Although the state has used survey data to levy low-level fines on several carriers,42 directory errors have persisted, leading to the filing of several lawsuits to protect consumers.43
We obtained survey data for all carriers subject to DMHC reporting regulations for psychiatrists and NPMHPs for reporting years 2018 and 2019. For 2018, these data covered 144 unique plans sold commercially (102 plans), via the Affordable Care Act marketplace Covered California (20 plans), or as part of the Medi-Cal program (22 plans). The 2019 data spanned 159 unique plans sold commercially (112 plans), via Covered California (22 plans), or as part of the Medi-Cal program (25 plans). This translates to 480,013 provider listings for 2018 and 666,941 provider listings for 2019. In terms of markets, for 2018 there were 380,421 observations for commercial plans, 52,498 for Covered California plans, and 47,094 for Medi-Cal plans. In 2019, the number of observations was 514,595 for commercial plans, 67,879 for Covered California plans, and 84,467 for Medi-Cal plans.
The present analyses of provider directory accuracy focused on the total number of providers successfully contacted, which serves as the denominator. This allowed us to discern whether the provider is appropriately listed or, if not, what the reason for the inaccuracy is. Ultimately, it provided us with the percentage of providers accurately listed. This approach is inherently conservative because we did not include providers whom surveyors could not reach, meaning directory accuracy is likely even worse than presented in these analyses.
For the timely access analyses, we conditioned the analyses on first connecting with an appropriately listed provider. The measures of timely access are as follows. For urgent care, for each specific attempt that connected with a provider, we measured whether surveyors were able to obtain an appointment with the provider they were trying to reach within 96 hours of the time of the call. For general care appointments, we analogously measured from the time of successful contact to the time of the scheduled appointment. For psychiatrists, timely access was achieved if the appointment was within 15 days, and for other NPMHPs, timely access was achieved if the appointment was within 10 days. In other words, we assessed timely access only for appropriately listed providers in the provider directory (and verified as such) and present the results for the percentage of providers who offer appointments within the time frames. Finally, when making comparisons for accuracy and timely access across markets, we used t tests to determine whether differences are statistically significant.
Inaccuracies of Listings
In 2018, surveyors were able to reach 68.1% of listings for psychiatrists and 59.1% of listings for NPMHPs to verify the accuracy of provider directory information (Table 1). Failure to attempt verification occurred when the survey attempt was met with refusal or because surveyors were unable to connect with anyone despite multiple contact attempts. The largest sources of problems for both types of providers were that providers do not practice in the listed county (13.8% for psychiatrists and 9.1% for NPMHPs), that the providers generally do not see patients (8.6% and 7.2%, respectively), and other contact information issues (6.6% and 6.9%). Conditioned on connecting with a provider, surveyors were able to verify as correct 66.6% of listings for psychiatrists (or 45.9% of listed providers) and 69.5% of listings for NPMHPs (or 41.7% of listed providers) (Table 1). Inversely, this means that even excluding unsuccessful survey attempts, provider directories were inaccurate in 33.4% and 30.5% of cases, respectively.
The results are essentially similar for psychiatrists in 2019. However, there seem to be improvements for NPMHPs. Surveyors in 2019 were able to verify directory information for 76.5% of providers and, conditional on successful contact, 81.1% of providers were appropriately listed. We are unable to determine whether these are true year-to-year improvements due to slight changes in the methods issued by the DMHC for 2019, as well as an increase in the number of survey attempts by carriers.44 We note, however, that access to mental health providers received substantial public and political attention during the time frame in question,45,46 perhaps refocusing carriers’ attention on the issue.
For both types of providers and across both years, there seem to be persistent and substantial inaccuracies in the directory entries for mental health providers. Although these levels of inaccuracy may represent some improvements to previous assessments,47 they nonetheless indicate that despite public attention, statutory and regulatory actions, and the levying of fines, inaccuracies persist.
Inaccuracies of Listings by Market
For psychiatrists in 2018 (Table 1), conditional on connections, surveyors were able to verify as correct 67.4% of listings for commercial plans, 63.2% for Covered California plans, and 63.8% for Medi-Cal plans; for 2019 the percentages were 67.7%, 65.2%, and 64.7%, respectively. Differences were statistically significant between commercial plans and both Covered California (P < .001 in 2018 and in 2019) and Medi-Cal (P < .001 in 2018 and in 2019) plans. However, all differences were less than 5 percentage points (Table 2 and eAppendix [available at ajmc.com]). There were no differences between Covered California plans and Medi-Cal plans.
When it comes to NPMHPs (Table 1), surveyors were able to verify 71.1% of listings for commercial plans, 65.8% for Covered California plans, and 61.5% for Medi-Cal plans conditional on connecting with a provider. For 2019, these percentages were 83.2%, 76.3%, and 71.4%, respectively. Again, the differences between commercial and both Covered California (P < .001 in 2018 and in 2019) and Medi-Cal (P < .001 in 2018 and in 2019) plans were statistically significant in 2018 as well as in 2019 (Table 2). The differences between commercial and Medi-Cal plans were approximately 10 percentage points in both years and approximately 5 percentage points comparing commercial and Covered California plans. Differences between Covered California and Medi-Cal plans were significant (P < .001) but less than 5 percentage points (eAppendix).
As explained previously herein, accurate provider directories are a crucial component of consumer access to medical care. But accuracy alone does not guarantee access. Once consumers have succeeded in finding an in-network mental health provider, they must also be able to schedule an appointment with that provider. To gain a fuller picture of access, we therefore also assessed whether surveyors were able to find appointments for urgent and general care. Herein we only present the results for cases in which the provider had previously been verified as listed correctly. As described in more detail earlier, we considered access to be “timely” if the time between a successful call and the appointment date for urgent care was less than 96 hours and for general care was less than 10 days for NPMHPs or 15 days for psychiatrists. We note that we assess timely access at the individual provider level because it comes closest to matching the experience of consumers in accessing care to an established provider. To provide a broader perspective, we also reanalyzed our data at twice these levels (results omitted) without any substantive improvements.
For psychiatrists, surveyors were able to schedule urgent care appointments within the time frame in 47.2% of cases in 2018 and 49.1% in 2019; for general appointments, timely access rates were 73.6% and 69.5%, respectively. For NPMHPs, surveyors were able to schedule timely urgent care appointments for 61.7% of the listings in 2018 and 56.9% in 2019; for general appointments, the percentages were 77.3% and 65.0%, respectively.
Timely Access by Market
We again conducted separate analyses by market. As with the directory accuracy analyses, diversity across markets, specialties, and years was apparent. For psychiatrists in 2018 (Table 3, Figure, and eAppendix), timely access rates for urgent care appointments were 44.2% for commercial plans, 52.7% for Covered California plans, and 65.9% for Medi-Cal plans. Rates were similar in 2019. For general care, timely appointments were available for 71.9% of cases for commercial plans, 77.2% for Covered California plans, and 83.2% for Medi-Cal plans. Again, rates were similar for 2019. Differences between markets were consistently significant (P < .001) (Table 4). Particularly noteworthy is the fact that Medi-Cal plans outperformed commercial plans by more than 20 percentage points and Covered California plans by more than 10 percentage points in both years. Differences between Covered California and commercial plans favored the former by more than 5 percentage points in both years.
The same patterns emerged for general care appointments (Table 3 and Figure) at lower levels, with Medi-Cal plans’ timely access rates exceeding those for commercial plans by more than 10 percentage points and those for Covered California plans by more than 5 percentage points. Differences between Covered California and commercial plans again favored the former by approximately 5 percentage points. All differences were statistically significant (P < .001) (Table 4 and eAppendix).
For NPMHPs (Table 3, Figure, and eAppendix), timely access rates for urgent care appointments were 60.7% for commercial plans, 63.4% for Covered California plans, and 69.0% for Medi-Cal plans in 2018. For 2019, the rates were 55.3%, 58.4%, and 68.0%, respectively. Although differences (Table 4) between Covered California and commercial plans were small, albeit consistently in favor of the marketplace plans, Medi-Cal plans once more provided the best timely access, exceeding commercial plans by 8 percentage points in 2018 (P < .001) and 13 percentage points (P < .001) in 2019, while exceeding Covered California plans by 6 percentage points in 2018 (P < .001) and 10 percentage points in 2019 (P < .001). For general care appointments, timely access across all 3 markets was just below 80%. However, Medi-Cal plans provided more timely access in 2019 compared with commercial plans (76.1% vs 63.4%; P < .001) and Covered California plans (76.1% vs 66.3%; P < .001) (eAppendix).
We analyzed provider directory accuracy and timely access to mental health providers for managed care products regulated by the DMHC for 2018 and 2019. Making use of more than 1.1 million observations collected over 2 years as part of the DMHC’s regulatory reporting requirements, the present findings offer the most comprehensive assessment of both issues to date for mental health care. Overall, provider directories were highly inaccurate for both psychiatrists and NPMHPs. Although rates were consistent for the former for both years, the data indicated a substantial improvement in the accuracy of listings for the latter, with improvements across all 3 markets. As mentioned previously herein, we cannot be certain that the improvements are an artifact of small changes to survey methods between both years, or whether the large increase in observations provides a more accurate overview of reality. The continued focus on mental health in California and nationwide, particularly on NPMHPs, may have indeed pushed carriers to improve the accuracy of the listings.46 We also found that commercial plans were consistently more accurate than Covered California and Medi-Cal plans. The present findings match those for other specialties.48,49 It may be that commercial customers exert pressure on carriers to provide better accuracy, or that the incentives for carriers are simply to ensure satisfied customers in this market by focusing more on accuracy. Differences were relatively small for psychiatrists across markets but substantially favored commercial plans over both other markets. Timely access for psychiatric urgent care appointments was achieved in less than half the contacts and for general psychiatric appointments was achieved in approximately 70%. For NPMHPs, urgent care access rates were approximately 60% in both 2018 and 2019 and general care access rates were approximately 80% in 2018 and 65% in 2019. Once more, we cannot be certain that the changes come as a result of small methodological changes, or whether the increase in survey attempts provided a more representative picture of the situation. We found that Medi-Cal plans’ timely access rates consistently outperformed plans from other markets, and Covered California plans generally fared better than commercial plans. This result matches findings for other specialties.48,49 Improved accuracy may potentially be the result of specific contractual obligations included in Medicaid contracts as well as federal requirements for Medicaid access.50 We note that access continued to be severely limited even at twice the timely access standards described previously herein.
There are limitations to this study. The analysis focuses only on managed care products in California. However, because of the size and diversity of the California insurance market, the results are still likely generalizable. Moreover, California may serve as a best-case scenario due to its strict legal requirements and relatively well-resourced regulators. Moreover, mental health providers are diverse and often highly specialized. We rely on the differentiation used by the DMHC, focusing only on psychiatrists on the one hand and NPMHPs on the other. More nuances might offer additional insights. Finally, we rely on the raw data from surveys conducted by carriers. However, the DMHC requires that carriers follow a specific method, and it seems unlikely that carriers would willfully circumvent or potentially cheat on this issue.
These analyses of mental health providers in California show that both provider directory inaccuracies and network inadequacy, assessed in the form of access to timely appointments, substantially limit access to mental health care for consumers. The present findings also have broader implications for the regulation of provider networks and the protection of consumers. As described previously herein, California’s efforts have been hailed as an exemplary benchmark for other states to follow. In addition, California is much more active in its network oversight than many other states, and very few states require anything even approaching the extensive timely access surveys that California plans must conduct. Although California’s laws and regulations are, on paper, some of the strongest in the country, they are still falling short, indicating the need to further expand efforts to protect consumers.
Author Affiliations: Yale University (AB), New Haven, CT; School of Public Health, Texas A&M University (SFH), College Station, TX; The Ohio State University (WYX), Columbus, OH.
Source of Funding: None.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (AB, SFH); acquisition of data (AB, SFH); analysis and interpretation of data (AB, SFH, WYX); drafting of the manuscript (AB, SFH, WYX); and critical revision of the manuscript for important intellectual content (WYX).
Address Correspondence to: Simon F. Haeder, PhD, MPA, School of Public Health, Texas A&M University, 212 Adriance Lab Rd, 1266 TAMU, College Station, TX 77843. Email: firstname.lastname@example.org.
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