There are four pieces of information that U.S. consumers need to make informed choices about their healthcare insurance coverage.
- Directory: What are the healthcare provider demographics, including specialty, locations, hours, credentialing?
- Coverage: Does the provider take a particular insurance plan?
- Benefits: What are the benefits, copays and formularies associated with my plan?
- Availability: Is the provider accepting new patients for this particular insurance plan and location?
Without having these capabilities in place, consumers are likely to make uninformed decisions or delay decisions. That in turn has significant health and financial impacts.
Healthcare provider directories have historically been supplied by the NPPES database. But it has been lacking in terms of being accurate, up to date, or even able to represent reality accurately. First, the overhead of making changes is quite high and there hasn’t been an easy way for a provider to delegate ability to make changes. Second, the incentives aren’t there. There are no penalties for abandoning updates and many providers don’t realize how frequently NPPES data is downloaded and propagated to consumer-facing applications. Third, the data model is fixed by regulation, but it cannot accurately represent the many-to-many relationships among practitioners, groups, facilities and locations. It also doesn’t adequately reflect the ability to manage multiple specialties and accreditations.
Incidentally, my work in the area of provider directories has been driven by the needs of DDOD. Specifically, there were at least five DDOD use cases that directly depended on solving the provider directory problems. But the actual problem extends well past the use cases. An accurate and standardized “provider dimension” is needed for any type of analytics or applications involving providers. That could include having access to insurance coverage information to analytics on utilization, open payments, fraud and comparative effectiveness research.
Addressing consumers need to understand their options in terms of coverage and benefits has historically been a challenge that’s yet to be solved. There are routine complaints of consumers signing up for new coverage, only to find out that their provider doesn’t take their new plan or that they are not accepting patients for their plan. These problems have been the driver for Insurance Marketplaces (aka, FFMs) instituting a new rule requiring QHPs (Qualified Health Plans) to publish machine readable provider network directories that are updated on at least a monthly basis. This rule, which is effective open enrollment 2015 and the technical challenges around it are described in detail in the related DDOD discussion on provider network directories. (Note that although the rule refers to “provider directories”, in reality it includes all 4 pieces of information.) CMS already collects all this information from QHPs during the annual qualifications process. It asks payers to submit template spreadsheets containing information about their plans, benefits and provider networks.
The seemingly simple question as to whether a provider is taking new patients has been a challenge as well. That’s because the answer is both non-binary and volatile. The answer might be different depending on insurance plan, type of referral, location and even time of day. It may also fluctuate based on patient load, vacations and many other factors. The challenged becomes even harder when you consider the fact that providers often don’t have the time or financial incentive to update this information with the payers.
Aneesh Chopra and I put together an industry workgroup to help determine how to best implement the QHP rule. The workgroup spans the full spectrum of industry participants, payers, payer-provider intermediaries, providers and consumer applications. It should be noted that we have an especially strong representation from payers and intermediaries, representing a substantial portion of the market. While looking at the best ways to implement the rule from a technical and logistical perspective, we identified a missing leg: incentives.
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The QHP rule and the specified data schema provides a starting point for the technology. Workgroup participants also suggested how to use their organizations’ existing systems capabilities to fulfill the rule requirements. We discussed logistics of how data can get moved from its multiple points of origin to CMS submission.
Through this exercise, it became quite clear that the implementation of the QHP mandate could make significant progress towards achieving its stated goals if certain actions are taken in another area — Medicare Advantage (MA). That’s because, much of the data in the proposed standard originates with providers, rather than payers. Such data typically includes provider demographics, credentialing, locations, and whether they’re accepting new patients. But at this point, marketplaces are able to only exert economic pressure on payers. MA, on the other hand, can leverage the STAR rating system to establish incentives for providers as well, which typically get propagated into provider-payer contracts. STAR incentives are adjusted every year. So it should be well within CMS’s ability to establish the desired objectives. They can also leverage the CAHPS survey to measure the level of progress these efforts are making towards providing the necessary decision making tools to consumers. At the moment, marketplaces don’t have any such metric.
It’s worth noting that Original Medicare (aka, Medicare FFS or Fee for Service) has an even stronger ability to create incentives for providers and I’ve been talking with CMS’s CPI group about publishing PECOS data to the new provider directory standard. PECOS enjoys much more accurate and up to date provider data than NPPES, due to its use for billing. But the PECOS implementation is not as challenging as its QHP counterpart in that we’re effectively publishing coverage for only one plan. So complexities around plan coverage and their mapping to provider networks don’t apply. But consumers still benefit from up to date provider information.
If we create incentive-driven solutions in the areas of Marketplaces, Medicare Advantage, Managed Medicaid, and Original Medicare, we might be able to solve the problems plaguing NPPES without requiring new regulation or a systems overhaul. We will be including the vast majority of the practitioners across the U.S., almost all payers and deliver the needed information for consumers to make decisions about their coverage.
Finally, we are partnering with Google to leverage the timing of the QHP rule with a deployment of a compatible standard on Schema.org. Doing so would help cement the standards around provider directories and insurance coverage even further. It empowers healthcare providers and payers to publish their information in a decentralized manner. Since updating information is so easy, it can happen more frequently. Third party applications could pull this information directly from the source, rather than relying on a central body. And the fact that search engines correctly interpret and index previously unstructured data means faster answers for consumers even outside of specialized applications.