Disconnects Between Provider Network Directories and Patient Preferences

ABSTRACT

Objectives: The question of what providers one has access to under their insurance coverage is crucial for patients in managed care. This study sought to examine information displayed in online provider directories and whether this information matched consumer preferences.

Study Design: A national survey (N = 4007) paired with an analysis of online provider network directories.

Methods: We conducted a quantitative content analysis of online provider directories from March 1 to May 30, 2023. A national survey of American adults was fielded from June 30 to July 2, 2023, to gauge preferences for information displayed in provider directories. Preferences and perceived importance of information elements that should be displayed in provider directories were contrasted with the data elements displayed in directories.

Results: We found that provider directories showed wide variations with regard to information displayed and in the amount of navigation required by patients. There were widespread instances of disconnect between patient preferences and data availability. Important data items related to care access and provider quality that were preferred by consumers were not universally presented in directories, such as availability of telemedicine (23% presented), information about office hours (58%), and disability access (59%). Approximately 7% of directories did not indicate whether a provider was accepting new patients, despite the requirement under the No Surprises Act to display such information. Further, certain marginalized populations may find it especially challenging to acquire information about providers.

Conclusions: Lack of attention to usability in provider directories may hinder the national goal of ensuring care accessibility for all.Objectives: The question of what providers one has access to under their insurance coverage is crucial for patients in managed care. This study sought to examine information displayed in online provider directories and whether this information matched consumer preferences.

Am J Manag Care. 2024;30(12):In Press

Takeaway Points

This study revealed widespread instances of disconnect between the information presented in online provider directories and the information sought by patients.

• Provider directories showed wide variations in information displayed and in the amount of navigation required by patients.
• Data items related to care access and provider quality fell short of what was preferred by consumers.
• Not all directories displayed information as required under the No Surprises Act.
• Marginalized populations can find it challenging to acquire needed information.
• Lack of attention to usability in provider directories may hinder the national goal of ensuring care accessibility for all.

Insurance coverage is merely the first requisite for accessible health care. The question of which providers consumers have access to under their insurance coverage is crucial for all patients in managed care. Choices of providers can have potentially large health and financial ramifications. Importantly, many provider attributes, such as provider quality,1 and logistic factors, such as convenient locations and business hours that fit with patients’ work schedules, play important roles in care delivered to patients.2 Patients may also have preferences for languages spoken or provider race,3 and online reviews may provide additional information to consumers that affect their choices.4 Choosing a plan with desired providers thus becomes one of the most significant decisions patients make about their medical care.5-8 Naturally, provider networks have become an important resource that consumers rely on when choosing an insurance plan.5

Federal and state governments have strengthened the informational requirements to consumers related to plan benefits provided by and restrictions that apply to insurance plans.9 Since 2022, the No Surprises Act has required insurance plans to include basic information in their provider network directories.10 Literature has indicated that website layout, information, and ease of use (eg, ease of navigability) are prominent influencers of website credibility to consumers.11,12 Moreover, several priorities in the 2023 CMS Framework for Health Equity outlined the importance of ensuring accessibility to health care in a way that is responsive to a patient’s needs and preferences.13 Yet it is unclear whether the information contained in network directories truly aids patients in accessing preferable, high-quality providers when they are needed. Indeed, we have limited knowledge about 2 crucial questions in this regard: What do insurers display in their provider directories, and does this information match consumer preferences? To address these questions, we fielded a national survey paired with an analysis of online provider network directories. To obtain a representative set of provider directories from various insurance carriers, we examined provider directories from all Affordable Care Act (ACA) Health Insurance Marketplace plans. Most of these carriers also serve commercial, Medicaid, or Medicare Advantage markets utilizing the same online provider directory architectures such as layout of information elements.

METHODS

Online Provider Directory Survey Data

We conducted a review of online provider directories for all active carriers in the ACA marketplace across all states and the District of Columbia from March 1 to May 30, 2023. The carriers in the marketplace were first identified using the HIX Compare (Robert Wood Johnson Foundation) data set for 2023,14 followed by verifications of active status by the authors (E.W.R., T.E., M.D., S.F.H.). Because states can vary in their policies of provider network directory requirements,15 we identified 320 unique carrier-state combinations in the HIX data set as the unit of analysis (eAppendix A [eAppendices available at ajmc.com]). Of these, 317 were still active at the time of our data collection. For each carrier, we simulated a search for primary care providers from a consumer perspective. Each provider directory was independently reviewed by 2 different researchers, with any discrepancies resolved by the research group.

For each directory, we recorded 24 items of information for provider and office characteristics. This information included various items required by the No Surprises Act (provider address, office phone number, specialty, and whether providers were accepting new patients)16 and other basic provider and office characteristics, including name, provider gender, race and ethnicity, provider type (medical doctor, doctor of osteopathic medicine, nurse practitioner, physician assistant), photo of provider, board certification, education, office hours of operation, hospital affiliation, and National Provider Identifier. We also recorded information about care accessibility and availability, including insurance accepted, remote services or telemedicine availability, extended hour availability outside normal business hours, inclusive care (eg, lesbian, gay, bisexual, transgender, and queer [LGBTQ+]–affirming care), language spoken by provider, whether the office was accessible to people with disabilities, quality-of-care rating such as star ratings for the provider, consumer reviews of the provider, age groups treated by the provider, and distance to the provider’s office.

We recorded data elements as “yes” or “no” on display in each provider network directory. To assess ease of navigation, we counted the number of clicks into web pages necessary to observe each characteristic. The landing page of a provider directory was considered the first page (1 click), where 3 to 4 primary care providers (physicians, nurse practitioners, or physician assistants) were examined. Some information required further clicking to the second page (2 clicks) or to the third page (3 clicks) to document data elements.

Consumer Survey Data

To study whether information displayed on provider directories aligned with patient preferences, we conducted a national survey of American adults from June 30 to July 2, 2023, using Lucid.17-21 A total of 7831 respondents opted into the survey, 7596 (97%) consented to take the survey, and 4007 respondents completed the survey (51%). Detailed survey methods using Lucid are illustrated in eAppendix B. Each respondent was presented with a list of 20 items identified from our online provider directory survey (eAppendix C). All items from the directory survey were included in the consumer survey except for provider name, specialty, address, and phone numbers because they were present on all provider directories. We first asked respondents which of the items should be presented in provider directories, followed by a question asking them to choose the top 3 items from the list that they would use to decide whether to seek care from a specific provider.

Analysis

We calculated the proportions of insurance carrier–state combinations that displayed specific items of information, the number of clicks needed for consumers to observe the data, and filter options in their provider directories. For the consumer survey data, we calculated the proportions of survey respondents who reported that the information should be presented in provider directories. The provider directory data and consumer survey data were contrasted. We conducted sensitivity analyses using logit regressions to estimate adjusted portions for each information item, which yielded highly similar findings to the unadjusted ones (regression details in eAppendix D).

By design, a provider network includes only a subset of providers in the market. This limitation further constrains the available providers who can respond to specific needs and preferences of traditionally marginalized patient groups. Therefore, we conducted stratified analyses for several disadvantaged or marginalized consumer groups. LGBTQ+ individuals often have unique health care needs, making it potentially important to learn whether an in-network provider offers some forms of inclusive care. We computed proportions of preferences for information about providers offering care that was inclusive of LGBTQ+ patients among respondents of different sexualities (heterosexual; gay or lesbian; bisexual, omnisexual, or pansexual; asexual or aromatic; queer, questioning, or unspecified). Because racial or ethnic congruences between patients and providers are believed to result in better patient care experiences,3 we calculated proportions of preferences for information on provider race and ethnicity by different racial and ethnic groups of respondents. Lastly, people with disabilities often face substantial access barriers that require accommodations from health care facilities and provider offices.22,23 Thus, we reported stratified proportions of preference for information on accessibility for disabled patients by self-reported disability status.

RESULTS

Information Presented in Online Provider Directories

Figure 1 presents available data elements identified in the online provider directories. All directories displayed provider name, address, telephone number, and specialty, and most displayed these data on the first page. Beyond this, there was wide variation in the availability of information across data elements. Provider type (99%), hospital affiliation (95%), language spoken (95%), gender (92%), travel distance (86%), and board certification (81%) were often listed in directories. Approximately 7% of directories did not indicate whether a provider was accepting new patients, contrary to the No Surprises Act requirement to display such information. Language spoken was present on the first page for less than 1 in 5 directories. The insurance plans accepted by providers appeared in 75% of directories, and when the information was present, only 27% of directories displayed it on the first page and 43% displayed it on the second page. Data on a provider’s race were present in only 9% of insurer directories and almost never showed up on the first page. Some provider characteristics that are highly relevant to care accessibility were only sparsely presented in directories, such as availability of telemedicine (23%), information about office hours (58%) and extended office hours (34% presented, 0.3% on the first page), and disability access (59% presented, 11% on the first page). Provider quality information was presented in 53% of directories. In general, patients had to navigate to the second or the third web page to view most data elements.

Contrasting Online Directories and Consumer Preferences

Our analyses of survey respondents showed a long list of items that consumers indicated “should be included” in provider directories (blue bars in Figure 2). Insurance accepted (92%), whether providers were accepting new patients (92%), provider quality (82%), and hospital affiliation (86%) were preferred by most consumers. Thirty-eight percent of respondents indicated their preference for the provider’s race and ethnicity data.

For the top 3 important data elements, respondents exhibited an even broader spectrum of preferences (eAppendix E). Fifty-two percent of respondents indicated that insurance accepted by the provider was most important, followed by whether the provider was accepting new patients (34%) and provider office hours (26%). However, most items on the should-be-included list, such as provider race, did not make it into the top 3.

Contrasts between what consumers perceived as valuable provider directory content and items of information available are displayed in Figure 2 by order of discrepancy between preferred (blue bars) and available information (orange bars). Information that was highly sought after by, yet remained largely unavailable to, consumers primarily concerned accessibility and availability. For example, 84% of consumers indicated that the availability of telemedicine should be included in provider directories, but only 23% of directories provided such information. Other items with large discrepancies included extended office hours (83% preferred, 34% presented), disability access (90% and 59%, respectively), and age groups seen by the provider (82% and 39%). Even the most highly desired information was not fully available, such as accepted insurance plans (92% and 75%) and regular office hours (93% and 58%). Lastly, although most respondents indicated that knowing about provider quality was helpful when choosing providers, only 53% of directories included this information.

Most online directories offered options to filter results based on desired characteristics such as patient age groups seen by the provider. However, most of the other important features named by consumers that may reduce a consumer’s searching time were not available as filter options (eAppendix F). Four provider characteristics were by far the most common filters: gender (97%), language spoken (93%), whether the provider was accepting new patients (90%), and hospital affiliations (83%). Less than 40% of directories allowed searches by whether telemedicine was provided (37.5%), provider type (37%), disability access accommodations (34%), provider quality (21%), age groups seen (17%), or provider race/ethnicity (8%).

Preferences in Provider Directory Information by Disadvantaged Populations

Figure 3 shows the preference for displaying provider racial and ethnic information by respondent race and ethnicity. Fifty-three percent of Asian respondents and 53% of Black respondents indicated their desire to have provider race displayed in directories, followed by Hispanic respondents (40%) and White respondents (34%). Yet when asked to rank importance of this information in selecting providers, provider race and ethnicity did not make the top 3 for any racial/ethnic groups. Only approximately 10% of Black respondents selected provider race/ethnicity as the most important information, and provider race/ethnicity was ranked even lower for other groups.

Figure 4 shows that most respondents who identified as gay or lesbian (80%); bisexual, omnisexual, or pansexual (79%); and asexual or aromantic (81%) viewed it as important for provider directories to display inclusive care–related information such as whether the provider offers inclusive care for LGBTQ+ individuals. One in 4 respondents who were gay or lesbian and 37% of those who identified as asexual or aromantic selected inclusive care as their top needed information in searching for providers, yet this item of information was only available in 29% of provider directories.

A similarly high share of respondents who reported a disability indicated preferences for learning about disability access information (90%), but this information was presented in only 59% of online directories (Figure 5). Among those with a disability, 11% ranked the importance of disability access information in their top 3, whereas only 5% of those who did not have a disability ranked the information in their top 3.

DISCUSSION

Combining novel public opinion data with real-world data of provider directories, our study explored the issue of whether the usability of provider directories matches with patient preferences. We found that online provider directories showed wide differences in which pieces of information were displayed and differed in the amount of navigation required by patients before reaching necessary information about a provider. Our survey revealed that health care consumers have heterogenous preferences. Most people highly valued information related to accessibility and financial consequences of health care, such as insurance accepted and hours of operation. However, information available in the online directories—especially important data items related to care access and provider quality, such as availability of telemedicine, disability access, or extended hours—fell short of what was preferred by consumers. For example, the quality of providers was less commonly presented despite being one of the most desired pieces of information. Recent data have revealed that publishing physician quality information can greatly reduce discrimination by health consumers against Black and Asian doctors when selecting providers while also helping patients travel much shorter distances for health care.13 The widespread instances of disconnect between information needed by patients and availability of information run counter to one of the intended roles of provider directories: helping patients find providers who fit their needs.24,25

That said, it is a notable success that more than 90% of all directories displayed whether providers were accepting new patients, as required under the federal No Surprises Act. This information was highly sought after by consumers, and the fact that 7% did not display this critical data demonstrates areas for improvement. At the same time, to collect and display accurate and timely data about providers can be logistically challenging for insurers and providers. The efforts required to keep data consistently updated are substantial. Thus, it was likely that by the second quarter of 2023, some plan directories were not fully compliant with the No Surprises Act. Our findings suggest that continuous government auditing and stronger enforcements are needed in the future.

Further, our findings suggest that certain marginalized population groups, such as LGBTQ+ patients, may find it challenging to acquire information about providers, potentially further constraining their health care access. Lack of crucial information may result in people choosing suboptimal plans that do not meet their needs for 1 or more dimensions of medical care. Moreover, information on disability accommodations and accessibility was missing from many directories. This potentially imposes extra burdens on people with disabilities, who are already more susceptible to barriers from inaccessible health care facilities or challenges in communicating with providers.15,23 Similarly, learning about whether a provider understands the unique health care needs of LGBTQ+ patients and extends efforts to provide better care to this group is important for that population when selecting providers. Missing that information can potentially further constrain in-network provider availability for LGBTQ+ individuals, a population traditionally underserved and frequently discriminated against in health care settings.16 Ultimately, this lack of information availability may disadvantage groups with lower resources or social capital, further aggravating inequalities in health.17

The disconnect between consumer preference and directory information can also further compound the structural health care barriers faced by racial minorities. Findings from our survey suggested that Asian and Black patients may prefer to learn about provider race prior to seeking care, yet this type of information was rarely available. Although there is growing interest in including race/ethnicity data in provider directories,26 this contrasts with certain valid reasons for concern. Displaying provider race information in directories could expose minoritized physicians to discrimination from patients because, historically, revealing a physician’s race was used to discriminate against and exclude Black physicians.27 Moreover, administratively, it is challenging for insurance plans to collect and display these data. Further, it is worth noting that a very small share of respondents ranked race/ethnicity information in their top 3 most important data elements when selecting providers. This implies that consumers value the data items that are perceived to be more immediately and directly related to care access (eg, insurance acceptance) more than providers’ demographic characteristics. Future research is needed to explore how online directory information display can be a mechanism to address racial inequities in health.

State and federal governments have become more invested in policies that govern provider networks. Although many states have regulations requiring accurate and up-to-date provider directories,10 only a small number of states have regulations aiming to enhance access for traditionally underserved populations as well as potential enforcement mechanisms.10 Some policies require that the provider directories be accessible to marginalized groups, although policies do not require that directories contain relevant information about access.15 As managed care plans continue to expand, it becomes increasingly important to ensure that the information in provider directories serves the accessibility needs of patients.

Limitations

There are several limitations to this study. First, the consumer survey relied on self-reported preferences. It is possible that some respondents were not fully aware of their preferences. Second, individuals’ preferences may change, and some providers may end their contracts with plans in the middle of a year. Also, insurance carriers may continuously update or modify information displayed online. Our cross-sectional survey could not capture this dynamic process. Moreover, we were unable to analyze the preferences of American Indian, Alaskan Native, Pacific Islander, and transgender individuals because of small subgroup sizes.

CONCLUSIONS

A substantial disconnect exists between provider network directories and patient preferences in information displayed. Lack of attention to usability in provider directories may hinder the federal goal of eliminating barriers to covered services in the health care system and ultimately lead to worse health outcomes and greater disparities.

Author Affiliations: Division of Health Services Management and Policy, College of Public Health, The Ohio State University (WYX, EWR, TE), Columbus, OH; Department of Environmental & Occupational Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus (MD), Aurora, CO; Department of Health Policy and Management, Texas A&M University (SFH), College Station, TX.

Source of Funding: Robert Wood Johnson Foundation (80527).

Author Disclosures: Mr Elton reports attendance of the 2024 Academy Health Annual Research Meeting and 2024 Southern Association for the History of Medicine and Science. Dr Haeder reports providing expert testimony for a case about provider directory inaccuracies and receiving funding from Robert Wood Johnson Foundation and Pennsylvania Insurance Department to study provider networks. The remaining 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 (WYX, SFH); acquisition of data (WYX, EWR, TE, MD, SFH); analysis and interpretation of data (WYX, EWR, SFH); drafting of the manuscript (WYX, SFH); critical revision of the manuscript for important intellectual content (WYX, EWR, SFH); statistical analysis (EWR); provision of patients or study materials (WYX, MD, SFH); obtaining funding (WYX, SFH); administrative, technical, or logistic support (WYX, EWR, TE, MD, SFH); coordination of data collection (TE); data review (TE); and supervision (WYX, SFH).

Address Correspondence to: Wendy Yi Xu, PhD, MS, Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave, Cunz Hall 208, Columbus, OH 43210-1132. Email: xu.1636@osu.edu.

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