Healthcare’s Dirty Secret: Broken Provider Data

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[00:00:41] Saul Marquez: Hello everyone! Welcome back to the podcast! I’m so excited to have you join us today because we’re going to be exploring really a topic that is a new reality that many Americans are facing. Even with insurance, the rising cost of healthcare is confusing. How do you get covered? Delaying care is a big thing, or skipping it altogether. Joining us today is the CEO of Madaket Health, Eric Demers. They conducted a national survey that reveals just how widespread this problem is and what it means for the future of healthcare access, but also what they’re doing about it. So, Eric, such a pleasure to have you on the podcast. It’s really been a while, so glad to have you back.

[00:01:26] Eric Demers: Great [00:01:00] to be here, Saul, always good to be on the podcast with you, catching up [00:01:30] on the current issues of the day.

[00:01:32] Saul Marquez: Yeah. And look, whenever I have questions about data in healthcare, like I just think Eric Demers, I think Madaket Health. With that said, I want to ask you, why did you commission this survey?

[00:01:44] Eric Demers: Yeah. So, we did this survey. We, back up for a second. We’re in the business of provider data. And when we speak to providers and payers all day, every day, right? So we have a really good grasp on the understanding that there’s a real data issue in America, right? It’s a real provider data issue in America. But what does that mean for patients? The everyday person, we’re so focused on talking to the people who pay and provide for the care, the insurance, and the providers, the everything they do is about treating care for their patients, having their patients to members access their care. And we know from the work that we do that there is a disconnect between patients being able to get the care where they need to and want to receive care. And what does that mean from a cost perspective? So ultimately, we did this survey to see what type of feedback we get from the industry being the patients and the everyday consumer, on do they have the access to the care that they need, or are they delaying or avoiding going for care because they can’t find the providers or the care they need that’s covered in their local community or by their plan? Ultimately, it was trying to connect the two sides of this conversation.

[00:02:52] Saul Marquez: Love [00:02:30] that. Yeah, no, with these types of surveys, sometimes you get the results and you’re like, oh yeah, yeah, I mean confirms what I [00:03:00] thought. But sometimes you get surprises. And for you, Eric, what would you say surprised you the most about the results?

[00:03:07] Eric Demers: So some of the results weren’t surprising because we see the data and we know that roughly half of all the provider data is inaccurate. So, the fact that half of Americans are putting off care because of that was a bit surprising, though, right? Roughly 47% we received from a survey said that they are delaying care because they can’t find it in network provider. And what was even more surprising to some degree was that the millennials were in even higher proportion. There were roughly 78% of millennials would delay care or choose to find another way, whether it be the digital approach or try something new or different, pay for it themselves or do it yourself model, because that the non surprising part there is that millennials are more likely to not want to wait for the system to figure itself out, but they’ll take action and do something on their own, right? So that part jive with thinking about the industry. But the just the numbers, the sheer numbers of number of Americans who are willing or are delaying access to care because they can’t find a provider who’s actually in their network, in their local area, or if they do, find a provider and find out that the cost, because their other network is too much from the pay, because it’s now it’s a percentage of a cost or charge that that’s too much for them, that they will also delay that care. So, that’s an impact on everyday Americans in the quality of their health.

[00:04:30] Saul Marquez: Yeah, [00:04:30] I mean, it’s it’s the reality for a lot of us out here that these numbers are the fact. And folks, Eric’s pointing to a big problem and that’s the data. Eric, I want to sidebar with you for a second. Like, why is the data so bad? It’s like banking. Banking does a great job. Like why can’t …, you know?

[00:04:50] Eric Demers: There’s no national standard on how you manage provider data. There’s no standard on how you exchange provider data. We tackled those issues on the patient [00:05:00] side decades ago, right, with electronic medical records and the EHRs and all the digital solutions we put out there to try and really help progress, importantly, the patient side of care. But what we haven’t done is bring that to the provider side of data, right? And ultimately, on the old days, most reimbursement in all those falls reimbursement was fee-for-service, right? It was why it was important to understand where your provider work and which provider, group or facility, or health organization they’re affiliated with. Ultimately, as long as they are a credentialed and eligible provider and … a claim, that claim would get paid because it was a percentage charge. It didn’t really matter where they were. In today’s world, more than 50% of our healthcare in the United States is conducted on a value-based care risk-sharing model, all of your Medicaid, Medicare, all that stuff, and a lot of all the other, a lot of other insurance plans. Now we’re into a plan where it’s important to understand how you enter the system. Do you have a primary care provider? Are the providers in that you are have ability to go receive care with? Are they in your network, so they’re covered, or are they out of network because they’re not part of your plan, but they would pay a percentage of whatever the charge is, right? So it makes it harder for the everyday American to get access to maybe the care that they want or need in the right time or place. And even when they do find a provider, we go on to our payer website. We search, find the doc, we find whoever we’re looking for. We try to make an appointment, and you call that doctor office, and they say, oh, tell me who your insurance plan is and you give it to them. They go, oh, we’re not in that work, or we don’t accept that insurance, or we don’t accept that plan for that insurance. And then you get frustrated because the payer website says it does, but that’s not accurate. And this is what comes back to the systemic problem, is that the provider data isn’t being sent to the payer in a timely fashion. And if it is, the payers can’t digest the many different ways that the data comes in and get into a standardized set of information that they can use every day to update their system. And because the two are so out of sync, the data on both sides doesn’t match. So, what the payer would may have in their database for the providers that work at a particular practice or location, more than likely doesn’t mirror who actually is working at that location. And this then causes the disconnect and ultimately the patient who’s trying to access the care gets frustrated because they can’t actually get to the endpoint that they thought they were getting to by following the path that’s in front of them.

[00:07:46] Saul Marquez: Yeah, [00:07:30] it’s a mess. Last question on this because I’m thinking, all right, what if the health system is vertically integrated? What if they are the payer and the provider? Is the data in better shape there, or do you find the same thing?

[00:07:59] Eric Demers: It’s not [00:08:00] in better shape. You often find the same thing because most of the integrated verticals like that, they still operate as separate entities, right? So ultimately in insurance companies, their job is to pay claims. It’s not to really manage all the other things around care in the way that we do today. They weren’t built that way. They’re trying to flex and be able to manage all those other things, which is why I believe more things get pushed back to the provider side of the house, because they’re more adept at managing some of those patient [00:08:30] facing requirements. But even within a vertically integrated system, you would think it would make most sense for them to be able to share the data because it’s under one umbrella.

[00:08:38] Saul Marquez: Yeah, you would.

[00:08:39] Eric Demers: Yeah, but they have the same systemic issues. Think of it this way. If we’re on the, if we’re in a large health system, they’re probably running a lot of really large systems. We have a large medical record system like an Epic, or a Cerner, or as an example, right? You have your revenue cycle management tools, which might be the same. It might be a different system. You have your human resources tools, understand who actually works there, and track everything on the provider or the clinician side. You likely have a credentialing platform to help make sure they’re participating, eligible to participate in. They’re actually credentialed to work there and all that stuff. All of those systems have provider data and locations, and information is loaded into them, and I can guarantee you that none of them match. None of them are in sync. And there’s no hierarchy like source of truth overarching directory that feeds from the system. So, if you are a clinician and a patient is in front of you. Who’s selecting that doctor? Are they selecting the right doctor at the right location? For what service is being done? Because they could be in that system ten times. Yeah, right? … can be confusing. And then, does that match what’s going on? The claim that’s being sent to the pair. And then does that match who credentialing says is eligible to participate? And are they even sending that information to the payer? So, if you think of it that way, it’s hard. And then you get to the payer side, and they’re getting updates and reports, flat files, fax, emails. And it makes it hard for them to get that eligibility into their side, even if they are delegated. Meaning like the health system is responsible for sending their, the eligible providers over to the payer, and they’re supposed to, and then add it to their system. Those lists are still wrong on the provider side. So, there’s a data cleanse issue. There’s a data accuracy issue. There’s a data sync issue. And that’s the area that we are focused on as an industry helping solve. But we’re really just trying to drill in and identify the problem. And then just by getting your data. It sounds simple. It’s not the files to say, let’s get your provider data. Who represents who is actually eligible to be here, over to the payers. So, they fix their side so it matches, and then we keep them in sync. That resolves so many issues. Underlying issues for access to care reduces denials, increases payments, increases quality of care. Because the patients on the track are they’re supposed to be. There’s so many benefits that just by fixing your data that we end up fighting administratively on the back end. Why didn’t I get paid appropriately? Why are they for backing money? Why didn’t all the 10,000 patients that I’m responsible for value-based care in my network, only a couple thousand come through the door, why? They go somewhere else, right? Those questions are, a lot of them are tied back to this one issue.

[00:11:25] Saul Marquez: Yeah. [00:11:00] That’s fantastic. Eric, I really appreciate the context. And so, getting back to the [00:11:30] survey, it all comes down to the data. It’s clear. What would you say needs to change first so that we could fix this.

[00:11:38] Eric Demers: The first thing we need to do is recognize that there’s an issue. For the longest time, there hasn’t been real recognition that the issue is big enough to actually focus on changing or improving it. The government a few years ago implemented some regulations for on the CMS side. The No Surprises Act was implemented, but didn’t have any teeth because there really weren’t penalizing anyone for not being compliant. They keep delaying those penalties, and that has highlighted the issue. But I feel so now with the value-based care structures being so much more prevalent in risk sharing with entities, and this the cost pressures, right? It’s so much harder. You have to be so much more efficient as a health system in order to stay profitable. If you can’t be profitable. And there’s so many, and managing these reimbursement models with payers has become more complex. So, the data has become super important. And so, this is an area where I think going forward, there’s much more recognition in the industry that it has become a problem. And even nationally, CMS is talking about how it’s a problem, but no one has brought forth a lot of solutions yet to resolve the problem. And most of the reason is a lot of people don’t have access to good data. There’s a lot of provider data in the industry, but it’s so old and inaccurate, and it keeps getting cycled back into the system that they may think that way. Hey, look, we went out and asked and to try and get better data and solve this issue, but ultimately, all we got was more of the same. And that has created this circle of same where we can’t seem to get past that 50%. And this is so we take a very different path here, and how we approach it. But that’s one of the reasons why the industry has been spending on this access.

[00:13:16] Saul Marquez: Yeah. [00:13:00] Thank you, Eric. It’s definitely and I was just thinking about an analogy here. All this dirty data, it’s like drinking dirty water and breathing dirty air. You’re going to be unhealthy. We got to find that clean water, find ways to cleaner sources. [00:13:30] And I guess really to run this thing off, what role does matic play in this and what can we do about it.

[00:13:37] Eric Demers: So, Madaket, it’s an interesting position that’s based on how we work in the industry. We for well over a decade, have been connecting payers and providers to ensure that doctors are enrolled with those plans and they get paid electronically, the way they’re supposed to get paid. We’re actually the only entity in America that does that second piece, and we work with all the large claims, processors, etc., to do that. What that has done is it put us in a unique position from a data-first perspective, where we have and our better understanding because doctors are touching our platform on a regular basis. We over 80% of providers have passed through our platform. And what that does is it allows us to have more accurate updates on where the provider is, what locations. Who are they affiliated with? What plan do they work with? Who are they enrolled with, etc. insurance-wise? And that information is critical when it comes back to helping organizations get their information up to date, so that those issues we talked about earlier, on finding our providers and network, can be resolved. The right kind of directory that’s more accurate for patients to be able to search. So that’s step one. Then we actually are because we’re a tech company, we have the ability to ingest a lot of awkward data. I’ll say it that way. That’s coming in from the industry and turn it into something of usefulness, and then push that information into the course systems that they need. So, we go out to the networks that the payers actually work with and connect them in that data into the payers. So, we can eliminate this delay of information getting in there. And it allows us to get those updates in the timely fashion that needs to be. And then ultimately, what we’re doing in the goal of our approaches is to sync the provider network and who actually represent who is the true representation at those locations with what’s in the payer directory, which ultimately will feed the patient-facing information and hopefully resolve some of these issues. So, we’re a bit of a different unicorn. We’ll say it that way than most in America when it comes to this.

[00:15:37] Saul Marquez: Yeah, well, you guys have a very unique position. I liken it back to the water analogy, Eric, of like that clean spring of water that I think we could take a sip of, and it goes back to the financials. There’s no more accurate things than the financials. And you guys sit at the core of that. Look, this has been awesome, folks. For everybody tuning in, we’ll make sure to put all of the links to get in touch with Eric, his company Madaket Health, as well as the survey, which we’re literally touching. Tip of the iceberg here. Take a look at that. It’s a big problem in our industry. It’s got to get solved. The industry is moving more to value-based care. This is the way that you’re able to do it sustainably and at scale. Eric, I really appreciate you jumping on and sharing these insights with us. [00:15:30]

[00:16:21] Eric Demers: Awesome. [00:16:00] I appreciate the time. It’s always great to see you.

[00:16:24] Saul Marquez: Likewise.

[00:16:29] Intro/Outro: Thanks for diving [00:16:30] into The Edge of Healthcare with us today. I hope these insights will fuel your journey in healthcare leadership. For more details, show notes, and ways to stay plugged into the conversation, head over to MadaketHealth.com. Until next time, stay ahead of the curve with The Edge of Healthcare, where lessons from leaders are always within reach. Take care of yourselves, and keep pushing the boundaries of healthcare innovation.