This post was co-authored with Aneesh Chopra, Chief Strategy Officer at Arcadia and first U.S. Chief Technology Officer under the Obama administration, and Hassaan Sohail, Senior Director of Product Management at Alma.
To truly solve the problem of patients finding and accessing in-network care, we need to look beyond reducing errors in payers’ provider directories. The goal of patients using directories is not to spend time perusing accurate records — it’s getting an appointment with a high quality provider who is nearby, in-network, and available. Rather than focus on directory accuracy alone, we believe that payers are well positioned to incorporate information about appointment availability into their directories and provide a method to directly book appointments. This addresses one of the greatest paint points for patients traversing the grueling last mile of provider selection. By integrating with provider appointment systems, payers are not only helping patients book appointments, but they may also be able to tap into the best ‘source of truth’ for directory data that providers can offer. Providing this seamless access to care represents a differentiated level of service by payers for their members and rises above the cat-and-mouse game regulators and payers are currently playing around directory auditing and accuracy.
Inaccurate data masks the supply-demand mismatch
Directory errors mask a deeper problem: payers’ networks are challenged to meet patient demand for timely care. All payers’ directories have errors, with the average payer’s directory less than 50% accurate. That means more than half of listed providers may be unavailable due to errors. Sifting through records to find an error-free listing is only the first hurdle, as finding somebody who can help with appointments can be challenging. ECG conducted a study showing that nearly 20% of the times patients call to schedule an appointment, a conclusive answer on appointment availability could not be provided. When patients are able to get conclusive answers, they may find that those appointments are unavailable for weeks or months. If only 50% of providers can schedule appointments within 38 days (a reasonable assumption since ECG found that the average wait time across all specialties and metro areas is 38 days), that further reduces the effective availability of network providers. After accounting for directory errors, inability to assess available appointments, and long appointment wait times, it’s likely that only 5% of directory record searches can lead to a timely appointment. Appointment availability across participating providers is the true measure of network robustness and access. If the available supply does not meet the member demand, then other interventions are required to ensure the network is sufficiently robust (expanding network capacity by recruiting more providers, optimizing current capacity by helping providers become more efficient, or more efficiently matching members seeking care with quality providers who are available). Understanding and improving the true availability of a payer’s network is essential to meeting patients’ needs for timely access to care.
Integrating payer directories and provider appointment systems
Today, payers employ extensive phone audits, secret shopper programs, and CAHPS surveys to understand member experience with provider availability. These approaches are labor-intensive, costly, and quickly outdated. To truly assess and solve the access problem, payers would benefit from accessing real-time appointment data directly from providers’ scheduling systems. Integrating with providers’ scheduling systems would allow payers to not only quantify the true availability of their network, but also list providers who are both in-network and available for appointments and give patients a clear path to timely care.
The ideal solution is a seamless link between payers’ directory data and appointment systems. Imagine a payer’s directory that not only shows a provider’s contact details and network status but also offers real-time appointment booking options. This would vastly improve patient experience by:
- Cleaning up directory data – This would allow payers to show only providers actively seeing patients, show the most available providers first in search results, and show them at the correct address.
- Increasing the availability of care – This would allow payers to display actual appointment slots.
- Streamlining appointment booking – This makes appointment booking phone calls unnecessary.
- Enhancing understanding of the provider workforce and network adequacy – This allows payers to measure the true availability of the population of providers in a given geography.
The current state of interoperable appointments
Currently, provider scheduling systems do not support open, industry standards that enable real-time scheduling across all providers on certified electronic health records. While payers have worked with proprietary platforms like Kyruus, DocASAP, and Availity to integrate appointment data and booking features into their directories, none of these platforms enables payers to offer this functionality across all their network providers. Similarly, ZocDoc has evolved from a consumer-facing appointment finder to refashion itself as a platform that links provider appointment infrastructure (primarily within EHRs and practice management systems) with developers of digital health and care navigation solutions. It is unclear from public information whether ZocDoc currently supports appointment booking within payers’ directories. One can imagine a world where ZocDoc, with its 175 integrations with EHRs, practice management systems, and other calendar solutions, scales up from its current 100k providers to the 2M providers who participate in payers’ networks. Whether it is ZocDoc, Kyruus, DocASAP, or some other vendor that gets there first, such coverage would mean the establishment of a platform that could service all payers’ directories to book appointments and to get accurate directory data directly from the source.
The opportunity for payers to begin offering seamless directory and appointment capabilities is hiding in plain sight within their acquisitions of provider organizations. Payers acquiring providers has been a trend over the past decade among the largest health insurers, and the strategy has produced record profits for payers like UnitedHealthcare and Cigna in the past year. Payers should look beyond intercompany eliminations and market power as leading goals for these acquisitions and should leverage their ownership and influence to build seamless appointment booking capabilities with their acquired providers. Exercising this more frequently would demonstrate the positive impact such functionality could yield, and would publicly signal good faith efforts by payers to leverage vertical integration not just for market power but to provide a better service to customers. All this said, the impact would still be limited to those providers where payers have an ownership stake, or where they are able to include contractual terms with providers to enable this functionality.
HL7 Confluence and GitHub repositories show that in 2016 and 2017, the Argonaut Project defined Implementation Guides (IGs) for both Provider Directory (for provider organizations, not payers) and Appointment Scheduling. For background, Argonaut is an HL7 working group that publishes Implementation Guides to accelerate the use of FHIR and OAuth in the healthcare industry. Most notably, their SMART on FHIR work paved the way for patients to access medical records via devices like the Apple iPhone and via a number of patient access apps. With regard to Provider Directory and Appointment Scheduling IGs, there have been anecdotes of adapted implementations of the IGs, but these are not widespread. Integrations that have been built between payers’ directories and provider appointment systems were done with considerable effort. If collaborators revisit these IGs and implement them at scale, they will provide the functionality needed to efficiently implement interoperable appointment scheduling. This includes querying providers by specialty and location, searching for available appointment times for specific providers, and booking appointments. If provider organizations and their EHR vendors begin to make these available, then payers could integrate with them one-by-one, or other tech platforms could efficiently integrate with them and aggregate appointment availability and booking capabilities for providers at a national scale on behalf of payers and others.
The other place where standards work has recently considered the concept of a universal platform is in the proposed National Directory of Healthcare Providers and Services (NDH). CMS released a Request for Information (RFI) in 2022, and it announced in October 2024 the initiation of a pilot for the NDH in Oklahoma. While the RFI and responses do reference direct appointment scheduling and provider-published directory APIs, the appointment scheduling use case is one that may not be introduced in the pilot phase.
Interoperable appointment scheduling for VA Community Care
In 2014, President Obama signed into law the Veterans Access, Choice, and Accountability Act establishing the Community Care program, enabling Veterans to seek care outside of VA instead of waiting for a VA appointment. In the following years, the proportion of care referred into the community increased to 44% of all VA care services across care settings in 2022. In 2023, VA began working with WellHive to enable direct scheduling between VA and external providers in the community. WellHive worked directly with community healthcare providers and collaborated with Kyruus and ZocDoc to integrate with EHRs and calendaring systems to support direct scheduling. VA has stated that the overall referral and scheduling process has been optimized from 26.6 to 17 days and that when WellHive is used, appointments can be scheduled in under 6 minutes. WellHive is yet to be deployed across all Community Care providers, and a House Committee hearing last month reveals that further implementations may be delayed or scaled back which may be due to budget shortfalls. This demonstration within VA is an example to payers of what interoperable appointment scheduling can achieve in terms of patient access to timely care.
How a universal directory + appointment platform may emerge
To summarize, there are three possible paths forward to see the increased use of direct-from-provider directory data, appointment discovery, and appointment booking:
- Interoperable Appointment Scheduling as an Industry Priority: Industry stakeholders could prioritize interoperable appointment scheduling, allowing payers to access provider availability data via APIs. This approach would let payers display up-to-date availability, allowing patients to book appointments directly. In the long-run, this would decrease administrative burden as payers would be less dependent on roster submission and phone calls to validate directory data. The heavy lift is on the provider and EHR side, and the beneficiary of the to-be data would be payers and their members. Some investment or incentives may need to be transferred from the payer community to providers to motivate them and their EHR vendors to build these APIs. Implementation of these technologies could decrease appointment-related phone calls, reduce payer-driven audit phone calls, streamline directory data submission, and lower patient acquisition costs for large provider groups and health systems. It remains to be seen whether these efficiencies are sufficient to motivate providers to adopt. Even if payers subsidized this technology completely, it would still require implementation effort and change management by provider organizations to adopt.
- Platform Expansion by Established Market Players: Companies like ZocDoc could expand beyond their own branded consumer platform to serve as a connective layer between payers and providers. By doing so, it could enable real-time scheduling across payer directories and could monetize the capital investments they made since 2007 in establishing real-time connectivity between its platform and provider appointment systems. This produces more booking fees sourced from payer directories and could give ZocDoc in-roads with payers to support a more complete journey (e.g., eligibility checks, cost estimation, and payments). Platforms with the widest coverage of providers are the best positioned. ZocDoc is a contender with its diverse set of EHR, practice management, and calendar integrations and its solid start of 100k providers. We cannot, however, rule out either a coalition of other scheduling platforms (e.g., Kyruus, Press Ganey, DocASAP), or Epic with its 36% of hospitals and 600k clinicians. Another path could be WellHive expanding its role as an aggregator of appointment endpoints as it is already doing within VA. This path is not mutually exclusive from the previous path, as established market players could collaborate to promote interoperable standards.
- Government Mandate or Development of a Universal Platform: In the absence of independent industry progress, government intervention could drive the creation or adoption of a standardized scheduling approach, making real-time appointment integration a reality. This would require government prioritization and would need to be worked into in-flight roadmaps for national platforms. CMS could, as an early signal to industry, decide to include appointment scheduling as a voluntary use case within the Oklahoma NDH pilot. In addition, CMS could collaborate with VA to promote the usage of standards-based APIs for interoperable appointment scheduling within VA Community Care. The resulting endpoints published by providers for VA could be eventually leveraged by payers and others.
By making progress towards standards, the healthcare industry can transform payers’ provider directories from lists of error-prone information into functional and accurate gateways for patients to access care. Even in the ‘established market players’ scenario, this will require refreshing previous work on appointment interoperability standards, normalizing and adopting those standards, and demonstrating win-wins among payers and providers.
With USCDI+, there exists a community pathway for stakeholders to work together towards a consensus. VA, CMS and other agencies can lead the way by promoting these standards among those healthcare providers they interact with and whom they pay. Payers should investigate with their network providers (especially those they own outright) to see what it would take to establish direct appointment booking capabilities from their directories into providers’ appointment scheduling systems. Industry adoption of standards around directory and appointment scheduling, along with adjacent work in digital quality and price transparency, will pave a clearer path for patients to have the information and capabilities to get the healthcare they need.