UPDATE (May 20, 2015) It looks like the forces for open data won this one! Here is the summary at fiercehealth and the actual policy change letter sent to payers.
If you spend much time in the patient community you meet someone who has been burned, badly by the “out of network” game that insurance companies play with/against healthcare providers.
Its simple, you get insurance plan A from company Z. Then you go to a specialist or get a scan or something and you ask, “do you take company Z insurance”? They say “sure”. You hand them the insurance card. What they don’t tell you is that they will be billing “out of network” which means they will be hardly covered at all.
You go to the insurance company, they point to the provider. You go to the provider, they point to the insurance company. Who is left with the huge bill? The patient.
Sometimes this gets really bad, in the worst cases important treatments to relieve suffering are delayed.
Are you tired of this? In order to fix this, we need to be able to build systems that tell us for sure which providers are in a given plan at a given time. We need to have that system available when we purchase our health insurance so that we can buy insurance that covers the doctors that we already use, or the ones that we want to use. We can imagine a theoretical tool called JustShowMeTheDoctorNetwork.com that solves this problem in a user friendly way.
There are lots of companies and journalists in the DocGraph community that would love to be able to build such a tool. DocGraph would love to provide the data for such a tool but right now that would require that we scrape the websites of every insurance company provider directory in the country. Those websites are really unfriendly to such efforts. The following text was taken from the user agreement of the doctor finder tool for Aetna:
Provider information contained in this directory is updated 6 days per week, excluding holidays, Sundays, or interruptions due to system maintenance, upgrades or unplanned outages. This information is subject to change at any time. Therefore please check with the provider before scheduling your appointment or receiving services to confirm he or she is participating in Aetna’s network. Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law.
The underlines are mine.
First, Aetna does not want anyone scrapping their website. They do not want people like DocGraph to create these data sets. They view their list of providers as a protected information asset, that only they can leverage.
But more importantly, they put the responsibility on “who is in what plan” squarely on the doctors. Which really means the patients, because the doctors websites will just say “check the insurance company website”. See what I mean about finger pointing?
Insurance companies, and healthcare providers need to be held accountable for their in vs out status. The only way to do this is to create open data set that maps Plans to Providers so that projects like JustShowMeTheDoctorNetwork.com is really easy to build.
The policy wonks at HHS/CMS/ONC et al get this. The have recently added the following text to the rules for the 2016 insurance plans.
…we propose that a QHP issuer must publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group, and any institutional affiliations, in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Exchange, HHS and OPM. As part of this requirement, we propose that a QHP issuer must update the directory information at least once a month, and that a provider directory will be considered easily accessible when the general public is able to view all of the current providers for a plan on the plan’s public Web site through a clearly identifiable link or tab without having to create or access an account or enter a policy number….(blah blah)…We also are considering requiring issuers to make this information publicly available on their Web sites in a machine-readable file and format specified by HHS.
underlines are mine…
This would solve the problem. Anyone who wanted to could create a website that showed what plans any given provider accepted, would be able to easily do so.
But they key word here is “propose”. Insurance companies in this country benefit greatly from the confusion about in network and out of network, and so do some unethical healthcare providers. There will be lots of people who oppose this proposal.
I hope that I have made the case that this information needs to be open and machine readable. If your convinced, then you can find the comment page to support this policy here. If you disagree with us, and you still want to submit a comment, you can use this page.
Please take a few moments and write in to support this policy change. The comments are due Dec 22nd 2014 which is basically tomorrow.
If you would like to read the in-progress comments from the DocGraph Journal you can go here. Feel free to cut and paste from out comments into your own comments, we would be flattered.
Feel free to tell them that I sent you 😉