Host Whitney Adair, VP of Growth at Orderly Health, recently chatted with professor Dr. Simon Haeder, of the School of Public Health at Texas A&M University, on the burdens and trends ahead for provider directories in the healthcare ecosystem.
Dr. Haeder focuses on patient access to medical care and policy changes for healthcare information exchange. How patients navigate provider networks and the challenges they face is a key focus of his recent research.
Dr. Haeder’s paper on Assessing Provider Directory Accuracy and Timely Access for Four Specialities in California covers the nuance in keeping information up-to-date across the healthcare provider network, including:.
- The impact on finding providers or specialists when inaccurate provider data exists
- The uncertainties for insurance companies presenting inaccurate information to consumers
- The inequities that arise and prevent people from seeking care who need it the most
The. U.S. healthcare system is complex and creates data fragmentation and uncertainty for patients, providers, and payers. Two big culprits? Inaccurate provider data and managing these directories. These obstacles result in healthcare inequities and delays in care for patients who need it the most. But it doesn’t have to stay this way.
Watch this <30-minute webcast that deep dives into the impact of inaccurate provider data and the trends ahead:
Transcript:
[Whitney]
Hi, everyone.
[Whitney]
Thanks for joining us today. My name is Whitney Adair, I’m the VP of Business Development at Orderly Health. We focus on provider data and empowering health plans and providers to better take control of that data today. I'm talking to Professor Simon Haeder I'm with Texas A&M University School of Public Health. Welcome Simon. Welcome back, happy to be here. Yeah. So good to see you. I was wondering if you could tell us a little bit about who you are and what you focus on.
[Simon]
As you said I'm a professor of Public Health here at Texas A&M University most of my work really focuses on access to Medical Care or health care more broadly for consumers and I look at it in a variety of ways big policy issues like the implementation of the Affordable Care Act and those kinds of things the opioid epidemic, surprise billing - all those kind of things. And then then I do a lot of you know Health Services kind of research that looks at specifically at how consumers navigate provider networks, how provider networks are regulated and what that means for consumers. You know, I do a lot of thinking about how we can do it better and what are the challenges we face in doing those kinds of things.
[Whitney]
Yeah, I love it. I mean this is an area that, you know, I understand a bit but I was so excited to hear about your research because I don't think it's a place that folks have focused on a ton as of yet. So, I was wondering why if you could tell us a little bit about your research and why it's important. And how you became passionate about it.
[Simon]
Yeah, so you know, I think you know, I used to work in the healthcare sector before I became an academic and so I worked a lot with consumers struggling to navigate the healthcare system. And I think that's a challenge that many people face but I could I got to see it firsthand. You know, I got to see it with low-income individuals, farm workers, minority populations that don't speak English and so you see like the biggest challenges up front. I think that's kind of shaped me and how I went into Academia thinking about these kinds of things and probably makes me a little bit different than most academics that you know don't get to have those experiences and so specifically thinking about you know the issue of Provider networks. I think that started coming up for me when the AC marketplaces were implemented in 2014.
[Simon]
There were so many articles in the newspapers about oh another hospital not included in the ACA Network you know Seattle's children's or Cedars-Sinai and I was like oh that's kind of interesting. So, you know, that's how I get a lot of my ideas reading news articles and you know the question that came up to me was like well how do these networks then compare
not only you know there was a couple of papers out that compared the ACA networks to um the overall supply of physician which is which it's a valid comparison my thinking that more was like how does it compare to what people like you and I with employer provided health insurance get like what would that what does that look like and so we looked at specifically hospitals because that was the big issue in the news because everybody cares about that big fancy hospital is in the network and so you know we wrote our first paper and made it into Health Affairs it was a really interesting paper. You know we did some follow-up papers and um you know I just got more and more fascinated by this this network issue or the network idea behind everything right. Because as you said networks I don't think are an issue a lot of people think about when they think health insurance.
[Simon]
I think most people think you know this kind of black and white question do you have health insurance or do you not have health insurance and everything in between is just kind of this black box. That’s lots of people. Policy makers to doctors I don't think care all that much about it. You know the more I work on it every day I feel like I learn more nuances and see more challenges and more opportunities to get this right for consumers.
[Whitney]
So I mean I'm listening to your answer and it sounds like it's really shaped by components of equity and access and making sure that people have access to care. Would you say that's true?
[Simon]
I think that's true you know I when I talk about these kind of issues I always say give the example of myself you know I'm by no means like you know rich and wealthy and all those kind of things but um I have a good job I have flexible work situation right so if I need to navigate the challenges of a provider Network for my kids or myself or my family I can probably handle that. Right? I might not be able to handle the anesthesiologist or radiologist that wasn't in my network. I didn't know about and you know all of a sudden charge me a million dollars. That’s probably you know beyond it. But if I can't find a provider for my children I can like figure out how to get my children into the care they need like I can't have the resources to do that and the skills and the education and all those kind of things. But then you think of a person that maybe English is not their first language um they work two hourly jobs jobs right. They don't quite understand the U.S Health Care system which is overly complex as we all know and you know you tell them you know this is your provider directory you know when you need care go you know call someone on a list and go there right. And then what happens if that's not the case right the provider is not there it's not listed correctly it's the wrong specialty or they go there in the first place into an urgent care center or something or a hospital and then it ends up not being in that Network and then they have to deal with the bills right.
[Whitney]
So I think it's one of the really big Equity issues of our time that has not gotten a lot of attention and not got any attention it should have gotten yeah that makes a lot of sense. So it sounds like there's a lot of hidden things that as you started digging into this world. What surprised you the most about provider directories that you've discovered so far?
[Simon]
So I think you know it comes back to one of the papers we wrote a couple years
back. What we looked at we went into this into this paper with the idea of let's see if providers treat patients who get that coverage to the ACA marketplaces different from the ones that get them through the employer. Because we know there's a little bit of
a difference in you know challenges and how Medicaid patients get into it into doctor's offices compared to commercial insurance. So we're like that was kind of like how bad is the difference or is there any difference in the first place? Because it's kind of commercial too right? And what we ended up coming out of this paper is this look how Incorrect and inaccurate these provider directories are and so the whole focus of the paper shifted away from this sure that was like a small difference. But that was like minuscule right? It didn't like move the needle hardly at all on the difference between commercial and AC Marketplace plans but this this massive amount of inaccuracy
that we found was just I mean it was just unbelievable and I wouldn't have believed it myself if I looked at the data. And it's like we've got to change the paper and you know the more you invest in this kind of you know the more resources you kind of get to work on these kind of issues over time you find more and more things that are just startling but you know you also do a lot of thinking it's like why is this so hard um yeah and then you know it's just a fascinating issue that as we said multiple times now it just doesn't get enough attention.
[Whitney]
Yeah and so the inaccuracy piece is I think is huge and a lot of folks might not even know that. So for people who are watching today who might not be acquainted with your research or what the numbers say what did you find in terms of inaccuracy in the directories you looked at?
[Simon]
Yeah so this paper was back I want to say 2016 you know that's the first time we really
looked at how inaccurate the data are. I think only a third of the listings were actually correct um you know you know there's a degree of incorrectness of course right there's the one all you know the address was slightly wrong or something which is challenging too if you drive there. And you know then that no one's there but then when you're like doesn't accept the insurance never worked there in the first place you're trying a primary care provider and it's a transplant specialist you know these are like big challenging issues. And then the question emerges is how much how much burden can we put on consumers to navigate these challenges like when is enough..enough. Right? How many providers do you need to call in order you know for that to be an acceptable situation? How much time do you need to waste? What happens if you go to one of these providers listed and they end up not being in your network and then you have to deal with the billing issues and out of out of pocket costs and all those kind of things? So it's a really complicated a policy issue that you know I wonder sometimes you know we're drifting kind of from the original question I suppose like why is this the place like why do we not address this issue why haven't we paid attention enough to this issue. I you know it's a complicated issue for sure and I I'm trying to understand more why this hasn't popped up in people's hits.
[Whitney]
Yeah I mean it seems like it's almost one of those tragedy of the commons almost. I'm just like talking off the cuff here but uh we're talking about data that come you know primarily from Health Systems but did it rely as well on contract information from payers too. So trying to get those to marry and talk to each other maybe it's something that everybody's sort of hoping the other party is doing their share to make it better and make it accurate for everyone.
[Simon]
Yeah you know I think it's kind of a reflection of the broader challenges and complexities of the U.S Healthcare System. Right? And you know you see you have worked in healthcare you know long enough everything is complex and they use
Healthcare System right nothing is easy right we have to hire a gazillion billing people because it's so complex. Right and nothing is simple and you know I think this is just one of these examples where we have a highly fragmented system. Change is you know hard and we haven't kind of a bit of an aversion often of government involvement to push people into a direction of solving these kind of issue it's a highly costly issue. In my eyes it requires a lot of technological investment to make this work on a you know grand kind of scale. To really address this comprehensively for consumers. And you know there's a lot of benefits for a lot of people to keep it the way it is right now. Where we're kind of like paying attention a little bit but not too much. But what it leaves out is of course the consumers right that are burden burdened really with the challenges of making that work for their families.
[Whitney]
Yeah, so when I listen to you it sounds a little bit like if we're thinking about obstacles to change like it's really around incentives and how we make sure that we incentivize keeping data up to date and that all stakeholders share in that goal and that sort of North Star. So that patients and consumers can access care reliably, right? That's
what I'm hearing.
[Simon]
I think that's true. I think if we you know if we find a solution to this I think most of us will be better off. Right? Consumers for sure. But I think also you know if you find a good solution that doesn't burden providers the way they're burdened right now I think that's a benefit from them. If they don't have to you know dedicate people to answering questions from insurers trying to keep their directories up to date right that's a great burden but it's also one of those things where you know. It opens itself up to a technological solution right this is something that doesn't require like a lot of skill and it doesn't necessarily require a lot of quite a lot of humans once you get over
the initial hurdle of this massive you know IT costly project. But as you pointed out right the incentives right now are really not going in the directions that they have to go in order to make the make it the big changes that we need here.
[Whitney]
Yeah. So we're in a really unique point of time. You know we've been dealing with COVID for two plus years now right. As you think about COVID and like the trends involved with us dealing with this virus. Has that also impacted this space in terms of patient access, finding providers, etc.? What are your views on it?
[Simon]
I haven't seen any data but you know just from thinking about it you know I think it made everything worse once more I think we just got distracted obviously by solving the issues surrounding covet you know as everybody knows it turned into a big chaos and we're worried about other things and provided directories and all those kind of
things you know and so I think insurers and everyone else you know kind of focused on trying to get us through this pandemic. Everything else was kind of secondary on this issue. You know the issues haven't gone away right? It's just like a general you
know? Everything else in the world didn't stop just because COVID. It’s still going on. You know the opioid epidemic's still in the world right? Everything else still going
on in the world. But we just got really distracted. Now it's I think that the important time is now to you know get some momentum going on these issues again. Because they're only going to get worse right more people are going to have these kind of products. The challenges only get bigger you know. The concerns of what Equity keep growing and all those kind of things. So you know COVID, I don't know if it's settled or not you know that's debatable but it's controllable I think at this point. So I think we there's massive issues in the U.S Healthcare System I think this is an important one that we out to refocus our attention to now as we move forward into more controlled
stage of the pandemic.
[Whitney]
We were all really distracted as you said for quite some time and it's good to have a little bit of breathing room in the Health Care system to be able to say how do we tackle these other really pressing issues? So yeah that's a really interesting point of view. So we've talked a little bit about like why this is such a big issue why should like the average person care about this?
[Simon]
Yeah that's a really good question I think the first one is one of personal interest you know. I think one of one of the issues one of the reasons we didn't, don't care as much about this issue is because most of the people in a given year, they're pretty healthy, right? They don't have to navigate the health care system and this is like the answer
to almost every problem we don't solve in healthcare. I don't know what the numbers are 70, 80 percent you know. They go maybe to a primary care provider once a year get a flu shot if you're lucky you know. I have maybe you know one specialist appointment or something right that's pretty simple to navigate but that can change in a moment right. You can have a child it can come up with like really, really severe challenges or you have a heart attack and all of a sudden you need to say cardiologist. Or, you're diagnosed with diabetes all of a sudden you did an endocrinologist and a podiatrist and all these kind of things. So, from a personal perspective I think this matters or you move right you know new environment and you have to find new providers all those those kind of things. So I think each of each one of us at one point in our life are going to be personally affected by the challenges of getting over this. I think everybody has a personal interest to think this kind of makes sense for people. I think it's also a question of where you know whatever we're getting presented is we're kind of paying for that product right. You purchase something from an insurer whether you do
it on the AC marketplaces or whether the government purchases for you on Medicaid
or whether your employer purchases for you right. We're purchasing kind of product and we're not really 100 sure what we're getting there right. It opens a lot of challenges too for insurers right because you're kind of committing yourself to presenting a product to consumers that you're probably not 100 sure of whether that's actually what people are getting right. So I think there's lots of personal interest to go around I think it's also you know a taxpayer kind of issue right I mentioned Medicaid right all of us are paying into Medicaid as taxpayers right and we're purchasing kind of services
again not 100 sure what we're getting you know? That leads into a more general issue of access and equity issues right. As I mentioned earlier a bunch of people you know that have good income and flexibility in their job and take care able to take time off they can kind of overcome these challenges and they have you know the background and the experience to overcome these kind of things. But for lots of people this is going to be a tremendous challenge. That might drive them into not seeking care and their health commission getting orders it might drive them into going into a more costly setting like an emergency department to see care. And then you know all of us are kind of affected by these kind of things right if you go to the emergency room when you shouldn't because you could have been seen in Urgent Care Primary Care Center. Then you clogging up that system right and we're you know just lots of these kind of issues that float around so I think there's many reasons we should be tackling this. For every one I think would benefit if we actually did.
[Whitney]
Yeah. And I think what I'm hearing is you know it might not be today but each and every one of us get affected by an inaccurate provider directories at some point in our lives right. I've talked to people about this probably more than the average person. It's surprising how many times people say I have a story about that and a lot of us have stories. Like even I like personally tore a ligament in my foot like called up my insurance they dictated over the phone a list of providers and their phone numbers that I could call and I called probably seven on the list and the first, the first six were either not open not accepting new patients. Two of them were spine people one was a hand person and I needed a foot person. So it's just sort of like pick your poison sort
of thing so it’s something that we might not realize that while each face but at some point in our lives we're going to come up against this. It affects all of us.
[Simon]
Yeah, I think that's absolutely right and you know it takes you know one quick thing
That happens in your life and all of a sudden you know your world's turned upside down. You have to figure out how to even find a provider that kind of sees you
Right? I think you know the additional thing though is here probably that because we don't exactly know what these provided directories look like and we have these inaccuracy issues that are well documented at this point by my own research and lots of other people it raises questions about the adequacy. I think the best way to
think about adequacy is like can you get into medical care within a reasonable time frame when you need it. The regulations and our whole setup is kind of like we need to have a broad enough provider network for that to kind of happen. But if we don't know
who's really in the provider network, then the question about how what you realize the access within that network actually looks like raises in the question like you know you weren't able to get see someone because they were overbooked. And they weren't accepting new patients that those providers are part of your network but they're not
they don't mean anything to you. And if we don't think about it more holistically in like what does the realized access for consumers in the network look like. Then that carries with it whole a whole set of other questions about how long should people have to wait when they have an urgent care issue. How long should people have to wait with
a life-threatening issue but something that makes their life really hard because they can't see a provider within a reasonable time frame. It’s months or even longer right to get into an into an appointment because there's just not enough providers that are actively seeing patients in a specific network. So, it's a much broader issue that's beyond the inconvenience of inaccuracy. We can talk about those you know to a blue in the face. But it means something for people on the back end right.
[Whitney]
For sure like there's just there's a breakdown in the information flow and sharing right. So it's something that I'm really thankful that it's become more and more top of
mind for health systems and payers. As we go thinking about the whole picture, what are your hopes for the industry? Who do you think has the biggest role to play to fix these problems?
[Simon]
Yeah, that's a good question. It’s a difficult issue for sure like this undeniable is super
Challenging, right? We have a lot of you know emerging integration going on the provider side but there's so many providers that are just like one or two people practicing somewhere, right? They’re seeing lots of different health plans and they're
spread out and people are moving all the time priorities are moving and you know
all those kind of things. This is a difficult issue like I think that that I freely acknowledge that the first step to fix it is going to be really difficult. It's requiring it's going to require some time and it's going to require resources. I think the way to shape the starting point is reshaping incentives. I think here that we you know someone is paying the cost of these inaccuracies right now, right? It's the consumers. You're paying for. You're paying your premium or your employer or the government is paying a premium but you're not kind of getting what you're supposed to be getting. You're not
getting care usually because it's not enough providers in your network because of these issues. So, we have basically externalized the challenge of this into individual consumers. I think we need to think about a shift to putting that kind of burden back on the entities that are more able to handle this to address the equity concerns that
we just discussed. And that's we need to create - an incentive structure where if
you can't get this right we're going to have to penalize it. Or, we have to incentivize you to get it right for additional payments right. There's two ways to handle this right pay less because they got it inaccurate or reward you because you got it accurate. I think
there's a combination of both of those things that we can think about. And I think we need some national leadership on the issue because we're not going to solve this issue in California alone. Or, in Texas alone or Vermont alone, right? There’s too much interconnectivity. People go across state lines all the time for care like we know these plans are sold across state lines. The Blue Cross plan, right, you can access care almost anywhere because of these agreements. So this is a national issue and we need to need a national leadership on the issue. I'm not sure if you know insurers they're going to tackle this on their own as I said. I think we need some incentive structure we need to think if people uh the industry technological companies as well as insurers and opportunity to get this solved. I think there should be standardization of course. Because we shouldn't you know just have everyone like kind of have an electronic medical record where no one is able to talk to each other that's not the solution that we need as well here. But there's ample opportunity to come up with a creative solution to address this kind of stuff. But there needs to be some national
leadership on the issue to push people or entities or insurers and all those kind of people into this direction. Where we're starting to think about this as not just a side issue or technological issue to be solved but something at the core of how we think about health insurance like we need to get the product that means you can get care when you need it. And you shouldn't have to worry about how you get into that care.
[Whitney]
So it sounds like part of it is policy of how do we structure incentives. But also leadership I mean we've seen this with value-based care, with ACOs right. It started out as a government policy and saying hey let's push forward on that. And the industry has really taken up the mantle and said you know this is important and we see that health care is growing in this way so we're going to push forward on it. Do you see a potential for the industry to evolve in a similar way around provider directories and accuracy?
[Simon]
Yeah, I think the one problem we have – and this was prior to a lot of these innovations that you know kind of have to be pushed at the federal level - is like no individual insurer really has an incentive to make the massive investment or purchase services or investing technology to make this work right. Because everybody kind of needs it and if you're the one investing massively in this then that's not falling behind everyone else in a competitive environment here. Because it's costly for sure. I think you know at the same time I think insurers have an interest in representing themselves as accurately as possible right. And they don't want to have to invest tons of resources to market stuff that they know is probably not what it really is for consumers. I think there's an interest you know. Ideally, I think you know insurers would tackle this issue and
agree on a common path forward. And as I said there was probably has to be some
nudging to make this this worthwhile on the federal level. You know, California they implemented some penalties for inaccuracies but they're really not enforced well. And you know all those kind of things. And I'm not sure I'm a great big fan of penalizing people. I think you know we just got some attention on the issue. Move some instances into the issue. Let there's really smart people in the industry and technology and you know things are evolving really quickly. There's lots of opportunity for it to do this creatively and not to you know on top down kind of approach. But I think there needs to be a little bit of a thread of a top-down approach. In the end if this doesn't get solved like because the question is like how long are you willing for people to figure this out right. Is 10 years the time frame is 20 years the time frame? Because in the meantime like it means real problems for consumers like this is an issue that matters to people right now. And we can't wait forever to just you know move on slowly and slowly and slowly.
[Whitney]
Absolutely. Well, Simon, I think you've given us a lot to think about and that this is a really multifaceted problem. That you know requires leadership like at the end of the day it affects patients plan members. And you know we need to align incentives and think about technology-based solutions. Because I think I've heard a little bit about you
saying there's we need investment in IT, And to like make sure this isn't such a manual process. I so appreciate your thoughts today and sitting down with me. I just want
to say thank you again and I'm really looking forward to future research that you put out.
[Simon]
It was a pleasure.
[End]