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Q&A: How and Why Blue Shield Led the Effort to Make Finding a Doctor Easier -- for All Californians

The effort to bring a real-time directory - that allows all Californians find a provider who takes their insurance - was led by Blue Shield of California
Sarah Summer

Q&A with Sarah Summer, Senior Director, State Policy & Strategy, and Associate General Counsel, Blue Shield of California

Provider directories have been problematic for decades, why was it suddenly so important for the healthcare industry to come up with a solution?

The Affordable Care Act (ACA) magnified the provider directory issues that the healthcare industry had been dealing with for decades. We had an influx of consumers entering the marketplace looking to confirm that their provider of choice was part of their new health plan.

Many of the plan provider directories they were searching had inaccurate data, causing confusion and frustration for patients, providers and plans. It was difficult for everyone, and made it more urgent for plans, providers and regulators to come up with a solution.

What was Blue Shield of California’s role in creating a solution?

A few key things happened that created a clear path to our involvement in the creation of the Symphony Provider Directory.

  • Our CEO Paul Markovich became chair of our national trade association’s Provider Directory Committee, which gave me a view into provider directory issues and projects across the country.
  • Blue Shield committed $50 million to find a solution in California as part of our Care1st acquisition.
  • The Department of Managed Health Care (DMHC) issued non-routine surveys for Blue Shield and Anthem Blue Cross (the two largest network plans on Covered California) to explore how we could improve our provider directories.

The survey was important because it highlighted that this wasn’t a problem that could be solved by health plans alone. Plans depended on providers to update their information when it changes. If we didn’t know that a provider was no longer accepting new patients, we couldn’t update the directory. On the other hand, providers were overwhelmed by having to update information for multiple plans, in a variety of formats. We needed the industry to come together and agree on a solution to truly make an impact.

How did the industry come together?

At first, we didn’t. In early 2016, we all had the same basic idea in mind – we needed to create one place for plans and providers to go and update information. The problem was providers, plans and even Covered California were all working with different vendors to pilot different solutions.

Around this time, California legislators passed Senate Bill 137. This bill was instrumental in bringing us together as an industry. It stipulated a shared responsibility between providers and plans to make sure directories were accurate. If we couldn’t figure this out, we would all have to deal with the consequences.

In August 2016, Blue Shield hosted the California Provider Directory Summit to inform and align key stakeholders. The result was the formation of three working groups made up of representatives from plans, hospitals, provider groups, HIEs, consumer groups and regulators to drive towards creating a single, statewide provider directory utility:

  • Data definitions and standards group – this group would define each data element, who was responsible for submitting it and what, if any, the authoritative data source would be. What we learned was that even something as straightforward as “name” could vary based on who was asking and when.
  • Business and technical requirements group – defined what the provider directory utility had to do based on the use cases developed during the summit.
  • Governance group – decided who would own the database. The group created criteria that any governance body would have to meet – a nonprofit with a history of successfully working with diverse stakeholders that was financially sound and agile enough to act quickly.

That last requirement was very important. There was some urgency to find a solution because of SB 137 requirements, but we also realized that the more time people spent on the pilots already in flight, the less likely they would be to pivot to this new solution. And we needed critical mass to be successful.

We awarded the planning grant to Integrated Healthcare Association in September 2017, followed by a soft launch grant in January 2018. We awarded the third and final grant in August 2018 for a multi-year, full-scale rollout. The utility was launched in January 2019 with the name Symphony Provider Directory and is well positioned to reach critical mass.

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Why do you think the Symphony Provider Directory will succeed when other attempts to consolidate provider directory information have not?

What differentiates this project from others in California and other states is that we took the time to do the foundational work and made sure that all stakeholders were engaged in a transparent and meaningful way. I also want to reiterate that the data accuracy and efficiency issues we face in health care are seldom technology problems. They’re usually stakeholder problems.

Another example would be health information exchange. It is imperative that we have accessible, longitudinal, comprehensive patient records. But the industry hasn’t yet come together to come up with a solution that everyone agrees on. The Symphony Provider Directory is a great example of what we can do in health care and health technology overall when we all come to the table.  

What’s next for the Symphony Provider Directory?

It’s important to remember that the work isn’t over. In the short-term, plans and providers will have to put time and resources into transitioning to the Symphony Provider Directory, but the long-term benefits to providers, plans and, ultimately, consumers will be worth it.

How does Symphony benefit consumers?

Right now, Symphony is not a consumer-facing provider directory. We felt that it didn’t matter how pretty the front-end website is, if the data was bad, then consumers still won’t be getting what they need. So, we focused on the data. However, Symphony will feed in to other multi-plan provider directories like Covered California. We’re also going to continue to explore ways to enable Symphony to meet those needs. Getting the foundational data right is the hardest part and we’re doing that with the Symphony Provider Directory.

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