Healthcare Policy January 13, 2023

Healthcare’s Groundhog Day

by Barry P Chaiken, MD

We all know about Groundhog Day, February 2, when Punxsutawney Phil emerges from hibernation and predicts whether we will have six more weeks of winter. But there is a second Groundhog Day, which is January 1. On that day, about 20% of patients switch healthcare plans and need to notify their providers and pharmacies of their new insurance coverage. January 1 is Groundhog Day for patients trying to access healthcare services. They must inform the plan of their current primary care physician or choose a new primary care physician since their existing PCP is no longer in the network. It is a tedious and unwelcome process that occurs the same way every time a patient changes her medical plan.

Without meaningful interoperability, this creates a massive hassle for patients and places an enormous administrative burden on hospitals, medical practices, and caregivers. For patients with pre-existing conditions like asthma or hypertension, medications that they have been on for years now need new pre-authorization by the medical plan administrator. The past approvals do not carry over, and medical records rarely can be used as evidence to obtain authorization.

Nurses in physician’s offices spend their January days on the phone or in front of a fax machine trying to provide insurers with the necessary justification for medications rather than caring for patients. We are not talking about $10,000 drugs here. Advair, a common asthma medication, costs just $275 yet often requires documentation for medical appropriateness. And when approvals are delayed, patients do not have the drugs they need to remain healthy.

Our healthcare system is filled with inefficiencies and friction in workflows that waste resources and hurt patients. And the current healthcare IT infrastructure fails to improve the situation. With a bit of creativity in its use, I think it could. Thanks. #medicalplan #insurance #groundhogday #healthcare #drbarryspeaks

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