Who Is the Provider Directory For?

I think policymakers, regulators, and many folks in Network hold two - somewhat in-tension - mental models of how provider directories are used.

The New Patient model assumes that a patient is using a directory to make a first appointment with a provider. They want to finally see a psychologist, say, or have just received a cancer diagnosis and suddenly need to see a specialist they hoped to never encounter.

If one is imagining a new patient as the provider directory user, access is key. Geographic proximity, average wait times, and availability-per-location are essential metrics. The friction a directory must smooth is difficulty getting an appointment.

The Existing Patient model assumes that a patient is looking at a directory to avoid billing friction. They already have established care patterns. The key question for a directory-user under this model is "can I see this provider in-network"; so identifying data elements like address, medical group, and network tier are paramount.

Regulatory requirements and commercial network analytics aren't explicitly oriented to one model or the other. Time-and-distance standards are arguably geared to the New Patient model - yet payers must list providers with closed panels, who exist only for the Existing Patient. Secret shopper surveys often dial the phone like a new patient but typically grade with an Existing Patient rubric. On the commercial side, disruption reporting is Existing Patient; breadth reporting is New Patient. The REAL Act seems mostly Existing Patient-geared.

To be sure, directories serve both patient types, so comprehensive oversight and plan monitoring will need to cover both. But saying which patient a given requirement is written for is a step we mostly skip.

I'm excited about the REAL Health Providers Act, whose final provisions should be out soon. What's been released to date seems aimed at the Existing Patient: verify every record, remove departed providers quickly, publish an accuracy score. A reliable answer to "can I see this doctor in-network" is vital to every patient, and I applaud it. My hope is that the Act states this goal outright - and that it's paired with companion changes on the New Patient side, like folding appointment availability into time-and-distance adequacy.

I'm also a bit nervous about the REAL Act. As recent "pharmacy desert" legislation has shown, a lot happens between statute and regulation, and again between regulation and a plan's actual compliance operations. Each handoff is a chance for an unstated objective to get muddled, and muddled objectives produce hodge-podge: metrics that are easy to report and hard to connect to patient outcomes. If the REAL Act tries to do too much, or leaves too much unstated, it may undershoot its potential.

I keep coming back to the idea that directory quality is at an inflection point. AI has changed the economics of managing provider data, and there seems to be some regulatory momentum around improving member experience with directories. But tools and attention only compound when they're pointed at a stated goal. The New Patient and the Existing Patient need different things from the same document, and pretending otherwise is how we get directories that serve neither well. You can't hold a directory accountable to a patient you never named.