Let’s Have APIs for Those Provider Directories!

This was a comment I submitted submitted to this proposed set of regulations on health plans participating in the ACA. (Use ctrl-F to search “provider directory” within the page). HHS is proposing forcing insurers to make their provider directories more accurate and machine readable, and it would be great for consumers if that was made the case–especially if APIs (which means basically giving access for other computers to read them) were mandated–here’s why:

Subject–Immediately updated  provider directories machine readable via APIs should be mandated for health insurers.

Finding accurate information about providers is one of the hardest things for consumers to do while interacting with the health care system. While regulation cannot fix all of these issues, these proposed regulations in section  156.230 can greatly help, But they should be strengthened by requiring (under subsection 2) that health insurers immediately add new information about providers in their networks to a publicly available machine readable database accessible via a freely available API.

Currently companies trying to aid consumers in provider search and selection tell us that the information pertaining to which providers are in a particular network is the least accurate of all data they can receive. For consumers the biggest question for plan selection is trying to find out which provider is in their plan, and at the least this requires searching multiple websites. Worse, particular insurer’s plans can even have the same name but can have different networks (in one instance in our personal experience Aetna in New York state had two different plans with effectively the same name but different networks). This is essentially impenetrable for consumers and that is assuming that the information on the websites is accurate or timely–which it is often not.

Provider search companies (like Vitals, Better Doctor, Healthgrades, Angies List)  often turn to third party vendors who sell information about insurance company provider networks but these services are both expensive and incomplete.

If each insurer provided information on its networks as soon as they change their data in their own database and had open API access to that  data set, provider search companies could immediately both receive this information and they could also build comparison tools across insurers’ different products. Very quickly a market would emerge in providing this information in a central place  (and quickly thereafter it could be included directly into the health insurance exchanges). This would help consumers who would be able to immediately understand which doctors were in the networks–often the most important part of their insurance selection decision.

In addition, providers themselves could query this data set, and if there was inaccurate information, they could request for it to be changed publicly, or “challenge” it–just as frequently retailers or vendors criticized on Yelp do. (For example, they could say, “no we don’t accept Aetna Gold” if the data was wrong)

Additionally, others will be able to include this directory information in yet more data sets that will help with the overall transparency of the system. Something those across the political spectrum agree is beneficial.

You will likely hear from insurance companies saying that this data provision is too hard or would take them too long to update. But the fact is that once the information about a provider being part of a network is collected, it gets entered in some data base within the insurer. As long as that database has a publicly available API, there’s no reason why there need be any additional expense or barrier to making that information public. Given the billions of dollars of taxpayers’ money we are currently giving insurers as part of the ACA, there is no reason why they shouldn’t make this minor change to their systems–which will vastly improve the experience of health care consumers and providers.

7 replies »

  1. Great initiative Mathew!

    BetterDoctor has free API that let’s you see which doctors are in which insurance network. Like Mathew points out it’s impossible to build 100% perfect data without direct access to the networks, and even then it could be very hard.

    Learn more about the BetterDoctor API at http://developer.betterdoctor.com

    I’d love to see more comparison tool to see how good the insurance networks are. We recently released an Insurance Radar tool that compared insurance companies based on size of network and quality of doctors. It gives an idea of different ways to compare networks.

    Try the tool at http://insuranceradar.betterdoctor.com

  2. No problems baring my contractual butt for the Greater Good, but I promise United and Cigna wouldn’t know what was in my contracts if they were published on the front page of the NYT.

    The operations side of these giants is truly mind-blowingly bad: what patients get exposed to is horrible, but the provider relations department is infinitely worse, pervaded top to bottom by nothing but “I don’t give a f***ism.”

  3. Granpappy, you may be right, but in this vision you would go onto some collectivist website and upload a photocopy of your contract, so that your patients and the government could all see!

  4. “But the fact is that once the information about a provider being part of a network is collected, it gets entered in some data base within the insurer”

    You would think so, but until you’ve dealt with these companies on a regular basis, you have absolutely no idea with what grotesque incompetence and disdain for accuracy this aspect of their operations is run.

    I’m frequently told by the big boys when I get into a dispute about fees or networks that it is impossible for them to access a copy of the still-valid contract that I am waving in their faces.

  5. Hear, hear, Matt! You have my proxy to add my name to the petition to implement your eminently sensible proposal.