Dr. Jane Zhu is an Assistant Professor of Medicine at Oregon Health & Science University’s (OHSU) School of Medicine. Zhu is the lead author on a new OHSU study on Oregon Medicaid mental health provider directories, which found that 6 out of 10 in-network providers listed are not actually available to see patients.
These “phantom” networks undermine access to care for patients most in need, according to the study. Zhu discusses some possible reasons for the directories’ inaccuracies and how they affect those seeking care in this Q&A.
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State of Reform: Can you discuss some of the team’s motivations for conducting the study?
Jane Zhu: “I am a primary care physician and a de facto mental health provider. When I refer my patients to specialty mental health care, I see how challenging it is for them to find a provider.
Providers are at overcapacity, they are changing affiliations, or there’s errors in contact information. So, we sought to find out the extent to which provider directories—which are lists of all the providers an insurer contracts with to deliver care for their members—reflect mental health providers that are actually seeing patients.
My research also has shown that mental health provider networks tend to be narrower than for other medical care. And that there’s lots of variation in how states monitor how adequate networks are [in the Medicaid program].”
SOR: Patients already face challenges in accessing mental health care. How does this exacerbate that issue?
JZ: “Patients often use provider directories to find their clinician. In mental health care, there’s already a shortage of providers, low participation of providers in the Medicaid program, high turnover of providers, and high demand for services.
So, already patients are facing an upwards battle to get mental health care. Add on to that provider directories that don’t actually reflect who’s available and active. Rather than have a frictionless glidepath to care that gets people with mental health conditions where they need to go, patients face layer after layer of access barriers.”
SOR: Can you discuss some possible reasons why these directories are not accurate? What can be done to correct the issue?
JZ: “First, it appears that a small set of mental health providers are providing the brunt of care for Medicaid patients, on top of an already small supply of mental health providers overall. A number of other studies have found this as well. Because care is concentrated among a small set of providers, it may be difficult for insurers to fulfill network adequacy requirements on paper, and that may be an incentive to include more providers [in-network] than may actually have the capacity or desire to see patients.
Second, it’s a lot of work to update and verify provider networks, both on the part of insurers and providers. Clinicians are moving, reducing their panel size, taking leave, finishing training, etc., and it’s a huge administrative burden for insurers to be able to keep up with that well.
Providers themselves contract with multiple payers, so keeping up with provider directory requests also takes a lot of time and effort. As is, there are no standardized, streamlined, pain-free processes for this information to be collected, verified, and distributed.”
SOR: In addition to updating these directories to reflect accurate information, what other types of initiatives might help Oregonians gain better access to mental health care?
JZ: “Long-term, we just need more mental health providers, both in Medicaid and across payer types. So, we need to be addressing retention and recruitment of mental health providers who can’t currently meet the population’s mental health needs. That means attention to provider reimbursement, administrative burdens, training and educational pipelines, and reducing burnout and attrition. And making sure we are investing in mental health delivery systems and giving mental health care the attention it deserves.
Short-term, state Medicaid programs are all trying to come up with their standards for network adequacy. Network adequacy seems like a pretty intuitive concept. We want to make sure people are getting the care they need when they need it. But in reality, it’s been very nebulous and difficult to operationalize.
So, the first implication is that relying on provider directories to assess network adequacy has shortcomings. It may be preferable to use a combination of data and methods—including claims data and patient surveys—to come up with meaningful metrics around what constitutes an adequate network.”
This Q&A was edited for clarity and length.