In modern America, “the bread” has changed. It is no longer found in a Parisian bakery but in a community health center, a pharmacy, or a hospital admissions office. It is insulin, chemotherapy, biologics and mental health care. Access to these essentials increasingly depends not only on medical need but also on administrative thresholds, shifting eligibility rules, and delay mechanisms that quietly determine who waits, who deteriorates, and who absorbs financial collapse as collateral damage.

When Illness Becomes Economic Collapse

Medical debt has become the most visible expression of this misalignment. More than 100 million Americans now carry health-related debt, much of it incurred despite having health insurance. For millions of Americans, a single diagnosis can be enough to destabilize their household finances permanently. Medical debt damages credit, constrains housing and determines employment options. It fuels chronic stress that contributes to poorer health outcomes. It punishes people not for recklessness, but for uninvited illness.

The consequences extend well beyond ledgers. Individuals carrying medical debt are significantly more likely to delay or avoid needed care, skip prescriptions or postpone follow-up visits. Families report cutting back on food, utilities or rent to manage medical bills. In this way, illness becomes an economic accelerant, pushing people already close to the edge into deeper instability. Survival may be possible, but recovery, both financially, emotionally, and psychologically, becomes elusive.

For patients with serious illnesses such as cancer, autoimmune disease, or rare conditions, the stakes are far higher. Financial toxicity has been associated with increased mortality among cancer patients, as out-of-pocket costs lead individuals to delay treatment or abandon therapy altogether. This occurs at the same time that medical innovation has never been more promising. Targeted therapies, biologics, and personalized medicine are extending life and improving quality of life. The contradiction is stark: scientific progress accelerates while access narrows.

How Administration Became a Barrier to Care

At the center of this contradiction sits prior authorization. Originally intended as a utilization management tool, it has evolved into a pervasive barrier to timely care. Physicians report that prior authorization routinely delays necessary treatment and consumes hours of clinical time, while patients wait often in pain, sometimes in medical crisis. In oncology, delays can mean missed treatment windows. In neurology, they can mean needless pain or irreversible decline. In mental health, they can mean crisis escalation and hospitalization.

Denial rarely arrives as a clear refusal. More often, whether intentional or not, care is slowed until the patient deteriorates, disengages, or pays out of pocket. The system follows the rule, but the consequence is the weight that the patient carries. What was designed as stewardship increasingly functions as deterrence, too often transferring the burden of cost control to those least equipped to carry it.

Public programs meant to stabilize access have not been immune to this dynamic. Medicaid and Medicare, established as pillars of the American safety net in 1964, now operate amid growing instability. Eligibility thresholds are a moving target. Redetermination processes remove coverage for administrative reasons, rather than due to changes in need. Patients in active treatment lose coverage mid-course, forcing physicians to scramble and patients to panic. Coverage churn disrupts care and erodes trust, encouraging people to delay engagement with a system that is no longer structured to protect them when they are most vulnerable.

Taken together, medical debt, administrative delay, and coverage instability are not isolated policy failures but a systemic pattern. The modern sick-care system excels at episodic intervention but struggles with continuity, predictability, and lived experience. It measures success in transactions rather than trajectories, focusing on efficiency rather than consequences. Innovation thrives, while access to these medicines frays.

Violence is Never Justified

Hugo warned of where this leads. When systems feel unreachable, when appeals are endless and context is stripped away, frustration hardens into despair—the search for bread. Despair does not always erupt visibly. More often, people delay care not because they are indifferent to their health, but because they are afraid of what seeking care will cost them financially and emotionally.

Violence is never justified. The murder of health insurance executive Brian Thompson must be condemned without qualification. It is a human tragedy, not a symbol, and should never be rationalized. At the same time, refusing to examine the conditions that fuel public rage that applaud the killer is a warning sign about how people experience health care as an institution that governs life-and-death decisions while feeling increasingly inaccessible and unaccountable.

In Les Misérables, bread was enough to keep Jean Valjean’s family alive, but it was the weight of rigid systems that nearly broke him. That distinction matters today. When access to health care is treated as something to be rationed through delay, instability, and administrative friction, survival may still be possible, but long-term stability is put at risk. Medical debt, coverage churn, and seemingly weaponized delays do not merely inconvenience patients; they reshape how people relate to illness, the government, and companies, and allocate care.

The path forward does not begin with sanctifying health care, nor with vilifying those who work within it. It starts with recalibration. Administrative tools must serve care rather than obstruct it. Eligibility for public programs must offer predictability, not whiplash. Access must be treated as infrastructure, something that must function under stress, not a privilege rationed through complexity. America’s health-care story is still being written. Its outcome will not be determined solely by innovation or cost control, but by whether systems are designed to work when people are most vuln

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Last winter, Amber Wingler started getting a series of increasingly urgent messages from the local hospital in Columbia, Missouri, letting her know her family’s health care might soon be upended.

MU Health Care, where most of her family’s doctors work, was mired in a contract dispute with Wingler’s health insurer, Anthem. The existing contract was set to expire.

Then, on March 31, Wingler received an email alerting her that the next day Anthem was dropping the hospital from its network. It left her reeling.

“I know that they go through contract negotiations all the time … but it just seemed like bureaucracy that wasn’t going to affect us. I’d never been pushed out-of-network like that before,” she said.  

The timing was awful.

The query: When a Missouri mom’s health insurance company couldn’t come to an agreement with her hospital, most of her doctors were suddenly out-of-network. She wondered how she would get her kids’ care covered or find new doctors. “For a family of five, … where do we even start?”

— Amber Wingler, 42, in Columbia, Missouri

Wingler’s 8-year-old daughter, Cora, had been having unexplained troubles with her gut. Waitlists to see various pediatric specialists to get a diagnosis, from gastroenterology to occupational therapy, were long — ranging from weeks to more than a year.

(In a statement, MU Health Care spokesperson Eric Maze said the health system works to make sure children with the most urgent needs are seen as quickly as possible.)

Suddenly, the specialist visits for Cora were out-of-network. At a few hundred bucks a piece, the out-of-pocket cost would have added up fast. The only other in-network pediatric specialists Wingler found were in St. Louis and Kansas City, both more than 120 miles away.

So Wingler delayed her daughter’s appointments for months while she tried to figure out what to do.

Nationwide, contract disputes are common, with more than 650 hospitals having public spats with an insurer since 2021. They could become even more common as hospitals brace for about $1 trillion in cuts to federal health care spending prescribed by President Donald Trump’s signature legislation signed into law in July.

Patients caught in a contract dispute have few good options. “There’s that old African proverb: that when two elephants fight, the grass gets trampled. And unfortunately, in these situations, oftentimes patients are grass,” said Caitlin Donovan, a senior director at the Patient Advocate Foundation, a nonprofit that helps people who are having trouble accessing health care.

If you’re feeling trampled by a contract dispute between a hospital and your insurer, here is what you need to know to protect yourself financially:

1. “Out-of-network” means you’ll likely pay more.

Insurance companies negotiate contracts with hospitals and other medical providers to set the rates they will pay for various services. When they reach an agreement, the hospital and most of the providers who work there become part of the insurance company’s network.

Most patients prefer to see providers who are “in-network” because their insurance picks up some, most, or even all of the bill, which could be hundreds or thousands of dollars. If you see an out-of-network provider, you could be on the hook for the whole tab.

If you decide to stick with your familiar doctors even though they’re out-of-network, consider asking about getting a cash discount and about the hospital’s financial assistance program.

2. Rifts between hospitals and insurers often get repaired.

When Brown University health policy researcher Jason Buxbaum examined 3,714 nonfederal hospitals across the U.S., he said, he found that about 18% of them had a public dispute with an insurance company sometime from June 2021 to May 2025.

About half of those hospitals ultimately dropped out of the insurance company’s network, according to Buxbaum’s preliminary data. But most of those breakups ultimately get resolved within a month or two, he added. So your doctors very well could end up back in the network, even after a split.

3. You might qualify for an exception to keep costs lower.

Certain patients with serious or complex conditions might qualify for an extension of in-network coverage, called continuity of care. You can apply for that extension by contacting your insurer, but the process may prove lengthy. Some hospitals have set up resources to help patients apply for that extension.

Wingler ran that gantlet for her daughter, spending hours on the phone, filling out forms, and sending faxes. But she said she didn’t have the time or energy to do that for everyone in her family.

“My son was going through physical therapy,” she said. “But I’m sorry, dude, like, just do your exercises that you already have. I’m not fighting to get you coverage too, when I’m already fighting for your sister.”

Also worth noting, if you’re dealing with a medical emergency: For most emergency services, hospitals can’t charge patients more than their in-network rates.

4. Switching your insurance carrier may need to wait.

You might be thinking of switching to an insurer that covers your preferred doctors. But be aware: Many people who choose their insurance plans during an annual open enrollment period are locked into their plan for a year. Insurance contracts with hospitals are not necessarily on the same timeline as your “plan year.”

Certain life events, such as getting married, having a baby, or losing a job, can qualify you to change insurance outside of your annual open enrollment period, but your doctors’ dropping out of an insurance network is not a qualifying life event.

5. Doctor-shopping can be time-consuming.

If the split between your insurance company and hospital looks permanent, you might consider finding a new slate of doctors and other providers who are in-network with your plan. Where to start? Your insurance plan likely has an online tool to search for in-network providers near you. 

But know that making a switch could mean waiting to establish yourself as a patient with a new doctor and, in some cases, traveling a fair distance.

6. It’s worth holding on to your receipts.

Even if your insurance and hospital don’t strike a deal before their contract expires, there’s a decent chance they will still make a new agreement.

Some patients decide to put off appointments while they wait. Others keep their appointments and pay out-of-pocket. Hold on to your receipts if you do. When insurers and hospitals make up, the deals often are backdated, so the appointments you paid for out-of-pocket could be covered after all.

End of an Ordeal

Three months after the contract between Wingler’s insurance company and the hospital lapsed, the sides announced they had reached a new agreement. Wingler joined the throng of patients scheduling appointments they’d delayed during the ordeal.

In a statement, Jim Turner, a spokesperson for Anthem’s parent company, Elevance Health, wrote, “We approach negotiations with a focus on fairness, transparency, and respect for everyone impacted.”

Maze from MU Health Care said: “We understand how important timely access to pediatric specialty care is for families, and we’re truly sorry for the frustration some parents have experienced scheduling appointments following the resolution of our Anthem contract negotiations.”

Wingler was happy her family could see their providers again, but her relief was tempered by a resolve not to be caught in the same position again.

“I think we will be a little more studious when open enrollment comes around,” Wingler said. “We’d never really bothered to look at our out-of-pocket coverage before because we didn’t need it.”

Author: Bram Sable-Smith: brams@kff.org, @besables

Illustrations: Oona Zenda: ozenda@kff.org

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HENRICO, Va. — Sheldon Ekirch spends a lot of time on hold with her health insurance company.

This story also ran on CBS News.

Do you have experience with prior authorization you’d like to share with us for KFF Health News’ reporting? Tell us here. COntact Us

Sometimes, as the minutes tick by and her frustration mounts, Ekirch, 30, opens a meditation app on her phone. It was recommended by her psychologist to help with the depression associated with a stressful and painful medical disorder.

In 2023, Ekirch was diagnosed with small fiber neuropathy, a condition that makes her limbs and muscles feel as if they’re on fire. Now she takes more than a dozen prescriptions to manage chronic pain and other symptoms, including insomnia.

“I don’t feel like I am the person I was a year and a half ago,” said Ekirch, who was on the cusp of launching her law career, before getting sick. “Like, my body isn’t my own.”

Ekirch said specialists have suggested that a series of infusions made from blood plasma called intravenous immunoglobulin — IVIG, for short — could ease, or potentially eradicate, her near-constant pain. But Ekirch’s insurance company has repeatedly denied coverage for the treatment, according to documents provided by the patient.

Patients with Ekirch’s condition don’t always respond to IVIG, but she said she deserves to try it, even though it could cost more than $100,000.

“I’m paying a lot of money for health insurance,” said Ekirch, who pays more than $600 a month in premiums. “I don’t understand why they won’t help me, why my life means so little to them.”

For patient advocates and health economists, cases like Ekirch’s illustrate why prior authorization has become such a chronic pain point for patients and doctors. For 50 years, insurers have employed prior authorization, they say, to reduce wasteful health care spending, prevent unnecessary treatment, and guard against potential harm.

The practice differs by insurance company and plan, but the rules often require patients or their doctors to request permission from the patient’s health insurance company before proceeding with a drug, treatment, or medical procedure.

The insurance industry provides little information about how often prior authorization is used. Transparency requirements established by the federal government to shed light on the use of prior authorization by private insurers haven’t been broadly enforced, said Justin Lo, a senior researcher for the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.

Yet it’s widely acknowledged that prior authorization tends to disproportionately impact some of the sickest people who need the most expensive care. And despite bipartisan support to reform the system, as well as recent attempts by health insurance companies to ease the burden for patients and doctors, some tactics have met skepticism.

Some insurers’ efforts to improve prior authorization practices aren’t as helpful as they would seem, said Judson Ivy, CEO of Ensemble Health Partners, a revenue cycle management company.

“When you really dive deep,” he said, these improvements don’t seem to touch the services and procedures, such as CT scans, that get caught up in prior authorization so frequently. “When we started looking into it,” he said, “it was almost a PR stunt.”

The ‘Tipping Point’

When Arman Shahriar’s father was diagnosed with follicular lymphoma in 2023, his father’s oncologist ordered a whole-body PET scan to determine the cancer’s stage. The scan was denied by a company called EviCore by Evernorth, a Cigna subsidiary that makes prior authorization decisions.

Shahriar, an internal medicine resident, said he spent hours on the phone with his father’s insurer, arguing that the latest medical guidelines supported the scan. The imaging request was eventually approved. But his father’s scan was delayed several weeks — and multiple appointments were scheduled, then canceled during the time-consuming process — while the family feared the cancer would continue to spread.

EviCore by Evernorth spokesperson Madeline Ziomek wrote in an emailed statement that incomplete clinical information provided by physicians is a leading cause of such denials. The company is “actively developing new ways to make the submission process simpler and faster for physicians,” Ziomek said.

In the meantime, Shahriar, who often struggles to navigate prior authorization for his patients, accused the confusing system of “artificially creating problems in people’s lives” at the wrong time.

“If families with physicians are struggling through this, how do other people navigate it? And the short answer is, they can’t,” said Shahriar, who wrote about his father’s case in an essay published last year by JAMA Oncology. “We’re kind of reaching a tipping point where we’re realizing, collectively, something needs to be done.”

The fatal shooting of UnitedHealthcare CEO Brian Thompson on a New York City sidewalk in December prompted an outpouring of grief among those who knew him, but it also became a platform for public outrage about the methods insurance companies use to deny treatment.

An Emerson College poll conducted in mid-December found 41% of 18- to 29-year-olds thought the actions of Thompson’s killer were at least somewhat acceptable. In a NORC survey from the University of Chicago conducted in December, two-thirds of respondents indicated that insurance company profits, and their denials for health care coverage, contributed “a great deal/moderate amount” to the killing. Instagram accounts established in support of Luigi Mangione, the 26-year-old Maryland suspect accused of murder and terrorism, have attracted thousands of followers.

The outpouring of anger at health insurers following the killing of UnitedHealthcare CEO Brian Thompson continues a cycle of rage that dates back decades.Read More

“The past several weeks have further challenged us to even more intensely listen to the public narrative about our industry,” Cigna Group CEO David Cordani said during an earnings call on Jan. 30. Cigna is focused on “making prior authorizations faster and simpler,” he added.

The first Trump administration and the Biden administration put forth policies designed to improve prior authorization for some patients by mandating that insurers set up electronic systems and shortening the time companies may take to issue decisions, among other fixes. Hundreds of House Democrats and Republicans signed on to co-sponsor a bill last year that would establish new prior authorization rules for Medicare Advantage plans. In January, Republican congressman Jefferson Van Drew of New Jersey introduced a federal bill to abolish the use of prior authorization altogether.

Meanwhile, many states have passed legislation to regulate the use of prior authorization. Some laws require insurers to publish data about prior authorization denials with the intention of making a confusing system more transparent. Reform bills are under consideration by state legislatures in Hawaii, Montana, and elsewhere. A bill in Virginia approved by the governor March 18 takes effect July 1. Other states, including Texas, have established “gold card” programs that ease prior authorization requirements for some physicians by allowing doctors with a track record of approvals to bypass the rules.

No one from AHIP, an insurance industry lobbying group formerly known as America’s Health Insurance Plans, was available to be interviewed on the record about proposed prior authorization legislation for this article.

But changes wouldn’t guarantee that the most vulnerable patients would be spared from future insurance denials or the complex appeals process set up by insurers. Some doctors and advocates for patients are skeptical that prior authorization can be fixed as long as insurers are accountable to shareholders.

Kindyl Boyer, director of advocacy for the nonprofit Infusion Access Foundation, remains hopeful the system can be improved but likened some efforts to playing “Whac-A-Mole.” Ultimately, insurance companies are “going to find a different way to make more money,” she said.

‘Unified Anger’

In the weeks following Thompson’s killing, UnitedHealthcare was trying to refute an onslaught of what it called “highly inaccurate and grossly misleading information” about its practices when another incident landed the company back in the spotlight.

On Jan. 7, Elisabeth Potter, a breast reconstruction surgeon in Austin, Texas, posted a video on social media criticizing the company for questioning whether one of her patients who had been diagnosed with breast cancer and was undergoing surgery that day needed to be admitted as an inpatient.

The video amassed millions of views.

In the days following her post, UnitedHealthcare hired a high-profile law firm to demand a correction and public apology from Potter. In an interview with KFF Health News, Potter would not discuss details about the dispute, but she stood by what she said in her original video.

“I told the truth,” Potter said.

The facts of the incident remain in dispute. But the level of attention it received online illustrates how frustrated and vocal many people have become about insurance company tactics since Thompson’s killing, said Matthew Zachary, a former cancer patient and the host of “Out of Patients,” a podcast that aims to amplify the experiences of patients.

For years, doctors and patients have taken to social media to shame health insurers into approving treatment. But in recent months, Zachary said, “horror stories” about prior authorization shared widely online have created “unified anger.”

“Most people thought they were alone in the victimization,” Zachary said. “Now they know they’re not.”

Data published in January by KFF found that prior authorization is particularly burdensome for patients covered by Medicare Advantage plans. In 2023, virtually all Medicare Advantage enrollees were covered by plans that required prior authorization, while people enrolled in traditional Medicare were much less likely to encounter it, said Jeannie Fuglesten Biniek, an associate director at KFF’s Program on Medicare Policy. Furthermore, she said, Medicare Advantage enrollees were more likely to face prior authorization for higher-cost services, including inpatient hospital stays, skilled nursing facility stays, and chemotherapy.

But Neil Parikh, national chief medical officer for medical management at UnitedHealthcare, explained prior authorization rules apply to fewer than 2% of the claims the company pays. He added that “99% of the time” UnitedHealthcare members don’t need prior authorization or requests are approved “very, very quickly.”

Recently, he said, a team at UnitedHealthcare was reviewing a prior authorization request for an orthopedic procedure when they discovered the surgeon planned to operate on the wrong side of the patient’s body. UnitedHealthcare caught the mistake in time, he recounted.

“This is a real-life example of why prior authorization can really help,” Parikh said.

Even so, he said, UnitedHealthcare aims to make the process less burdensome by removing prior authorization requirements for some services, rendering instant decisions for certain requests, and establishing a national gold card program, among other refinements. Cigna also announced changes designed to improve prior authorization in the months since Thompson’s killing.

“Brian was an incredible friend and colleague to many, many of us, and we are deeply saddened by his passing,” Parikh said. “It’s truly a sad occasion.”

The Final Denial

During the summer of 2023, Ekirch was working full time and preparing to take the bar exam when she noticed numbness and tingling in her arms and legs. Eventually, she started experiencing a burning sensation throughout her body.

That fall, a Richmond-area neurologist said her symptoms were consistent with small fiber neuropathy, and, in early 2024, a rheumatologist recommended IVIG to ease her pain. Since then, other specialists, including neurologists at the University of Virginia and Virginia Commonwealth University, have said she may benefit from the same treatment.

There’s no guarantee it will work. A randomized controlled trial published in 2021 found pain levels in patients who received IVIG weren’t significantly different from the placebo group, while an older study found patients responded “remarkably well.”

“It’s hard because I look at my peers from law school and high school — they’re having families, excelling in their career, living their life. And most days I am just struggling, just to get out of bed,” said Ekirch, frustrated that Anthem continues to deny her claim.

In a prepared statement, Kersha Cartwright, a spokesperson for Anthem’s parent company, Elevance Health, said Ekirch’s request for IVIG treatment was denied “because it did not meet the established medical criteria for effectiveness in treating small fiber neuropathy.”

On Feb. 17, her treatment was denied by Anthem for the final time. Ekirch said her patient advocate, a nurse who works for Anthem, suggested she reach out to the drug manufacturer about patient charity programs.

“This is absolutely crazy,” Ekirch said. “This is someone from Anthem telling me to plead with a pharmacy company to give me this drug when Anthem should be covering it.”

Her only hope now lies with the Virginia State Corporation Commission Bureau of Insurance, a state agency that resolves prior authorization disputes between patients and health insurance companies. She found out through a Facebook group for patients with small fiber neuropathy that the Bureau of Insurance has overturned an IVIG denial before. In late March, Ekirch was anxiously waiting to hear the agency’s decision about her case.

“I don’t want to get my hopes up too much, though,” she said. “I feel like this entire process, I’ve been let down by it.”

The post ‘They Won’t Help Me’: Sickest Patients Face Insurance Denials Despite Policy Fixes appeared first on Medika Life.

When skilled medical care is guided by empathy, it becomes something greater. It rises beyond competency. It becomes a connection. It becomes care.

We celebrate survival and measurable outcomes — and we should, however, carry with us what people carry with them long after the diagnosis, such as what was done and how we were treated in the process. It is when a physician takes the time to explain the next steps clearly. It’s the kind gesture from a nurse, the smile behind the mask, the call that came just to check-in. These human elements are not extras. Communication is always part of care.

The most enduring part of the health journey is whether people survive and how they are treated while they try.

People Always, Sometimes Patients

People navigating illness rarely rave about systems. They remember moments — how a physician sat and listened, the hand on the shoulder, the honest, unhurried explanation. They speak of kindness, clarity, and dignity. Empathy is not an accessory to care — it is the essence of care. The data backs that up.

A Medscape report confirmed that patients with chronic pain experienced significant improvement when treated by physicians who exhibited empathy. In Patient Education and Counseling studies, empathy led to better communication, treatment adherence, and clinical outcomes. Harvard Medical School research shows that when patients feel heard and understood, they’re more likely to engage in their care and experience improved results. This is more than perception — it’s physiology. Stress levels drop, trust increases, and healing accelerates.

Empathy isn’t a “soft skill.” It’s a clinical tool that improves outcomes and humanizes healthcare. In How Doctors Think, Jerome Groopman, MD, reminds us that data does not replace presence: “Statistics cannot substitute for the human being before you; statistics embody averages, not individuals.” Every patient has a backstory — a unique path to the clinic door — and when physicians listen, they gain context and insight.

In 1993, the late Arnold P. Gold, MD of Columbia University, reimagined the start of a medical student’s journey by introducing the “White Coat Ceremony” — a symbol of professionalism and compassion in care. His vision was simple but profound: remind future physicians from day one that medicine is about people, not just pathology.

The ceremony expanded to nursing and other health professions under the leadership of Richard I. Levin, MD, Professor Emeritus of Medicine, Department of Medicine at NYU Langone Health and former President and CEO of The Arnold P. Gold Foundation. “We mourn for him,” Dr. Levin said of Dr. Gold, “but as we celebrate his unique life, we can all carry his legacy forward in love.” The White Coat Ceremony, born from one physician’s belief in the power of human connection, can be a learning experience shaping the heart of health professionals.

The Clinicians Who Lead with Heart

This approach is not hypothetical. It’s exemplified by physicians whose names are synonymous with excellence and empathy. These are outstanding physicians I have encountered through the years. They and their office or department teams collectively demonstrate that knowledge and empathic caring create memorable medical experiences.

Empathy is not just a soft skill in healing — it’s a clinical art. It allows a physician to step into the world of their patient and grasp their experience emotionally, intellectually, and behaviorally. However, empathy goes further: it means communicating that understanding, validating the patient’s concerns, and transforming the exchange into therapeutic action. Empathy becomes the bridge between the healer and those seeking to be healed — where listening becomes treatment, and understanding becomes care.

This fusion of clinical excellence and genuine empathy distinguishes exceptional physicians in healthcare delivery. These physicians prove that it is possible to be both an outstanding clinical physician with a heart and conscience:

A distinguished urologist in New Jersey, Joseph V. DiTrolio, MD, who only recently announced his retirement from clinical practice, seamlessly integrated innovative techniques with a patient-first philosophy for years. His approachable demeanor — insisting patients call him “Joe” — fosters a comforting environment where individuals feel genuinely valued. Beyond his clinical practice, Dr. DiTrolio has contributed significantly to urology through product development and holds several patents. His commitment to education is evident in his Clinical Professor of Surgery role at New Jersey Medical School.

Serving as President of Mount Sinai Fuster Heart Hospital and Physician-in-Chief of The Mount Sinai Hospital, Valentin Fuster, MD, embodies the integration of empathy and leadership. His holistic approach to cardiovascular health — encompassing research, patient care, public health policy and education — has made a global impact. Dr. Fuster’s development of a cardiovascular “polypill” reflects his dedication to accessible patient care, reducing cardiovascular mortality by 33 percent among heart attack survivors. His contributions have been recognized with numerous accolades, including the World Heart Federation Lifetime Achievement Award. He makes himself 100 percent available, whether focusing on a patient in the ER awaiting treatment, rebuilding Haiti’s health system, focusing on the needs of communities in Spain, or leading a global professional association. His heart is in everything he engages.

As Chair of Radiation Oncology at Cooperman Barnabas Medical Center, Alison Grann, MD, exemplifies the harmonious blend of clinical precision and emotional intelligence. Recognizing the emotional weight of specific diagnoses, she ensures that every patient interaction — from reception to treatment — is infused with warmth and respect. Her leadership fosters an environment where patients feel seen and heard, reinforcing their trust in their care. Dr. Grann’s commitment extends beyond patient care; she actively engages in research and holds a Clinical Assistant Professorship at Rutgers Cancer Institute of New Jersey.

At Weill Cornell Medicine, Allyson J. Ocean, MD, stands out as a leading gastrointestinal oncologist and patient advocate. Her compassionate approach clarifies the uncertainties of oncology, deeply resonating with patients. As a co-founder of “Let’s Win Pancreatic Cancer,” she heeded the counsel of a communication leader – one of her patients – the late Anne Glauber – and turned the pancreatic cancer journey into a broader mission to extend others’ lives. Dr. Ocean’s dedication to patient-centered care is further demonstrated through her roles at The Jay Monahan Center for Gastrointestinal Health and her active involvement in clinical research and education.

At NYU Langone, Lawrence (Larry) Phillips, MD, delivers exceptional cardiovascular care rooted in empathy and connection. In a specialty where urgency often overtakes interaction, he slows the pace — making listening his first intervention. Patients consistently highlight how seen and heard they feel, a testament to his people-first approach. Board-certified in Internal Medicine and Cardiovascular Disease, Dr. Phillips also serves at NYC Health + Hospitals/Bellevue and is a passionate advocate with the American Heart Association, leading grassroots efforts to expand CPR training and community heart health education.

As Chief Medical Officer of WebMD, John Whyte, MD, MPH, bridges the worlds of clinical practice, public health, and consumer education — delivering trusted health information with empathy and clarity. He sees patients weekly, grounding his clinical leadership in real-world care. Dr. Whyte’s books, including Take Control of Your Cancer Risk and Is This Normal?, reflect his commitment to guiding people through their health journeys with candor and compassion. A former leader at the Food and Drug Administration and the Centers for Medicare & Medicaid Services, he brings a public health lens to his work, ensuring each message empowers and every patient feels seen.

These physicians exemplify how empathy and medical expertise transform patient care and cement community admiration. They do more than heal — they restore faith in the system and dignity to the patient’s journey.

Stop Calling Us Beneficiaries — We’re Paying Customers

Empathy must extend beyond the individual clinician and become a defining trait of our health system, from how we write policies to how we answer phones.

Too often, people in need of care face frustration instead of compassion. Insurance denials, confusing bills, impersonal communications — these compound the stress of illness. But forward-thinking organizations are challenging that norm.

In the health industry, we often claim that the patient is at the center of care and that naïve Band-Aid should be ripped off. The murder of Brian Thompson is a tragic and terrifying wake-up call to the US health insurance industry. However, the headlines have receded into the background, and with the passing news cycle, so has the urgency to evolve the care coverage system.

The public reaction to Thompson’s death gives us an essential opportunity to recognize that we have lost the trust of many of the people the sector seeks to serve. The trauma of this terrible moment can be addressed in one of two ways — avoidance or engagement. This event must catalyze health companies to reassess their approach to patient care and public trust.

Profitability and service to the patient aren’t two separate outcomes. Investing in interventional care and providing that care are also inextricably intertwined. The industry should consider several key recommendations. Some companies do what is needed to treat “beneficiaries” and “members” more like paying and valued customers.

MetLife and Guardian Life have partnered with Empathy, a platform designed to support beneficiaries through bereavement. These companies understand that losing a loved one is not just a claims process; it’s a human-customer-like — experience. They’ve committed to making that moment one of guidance, not bureaucracy.

Operationally, insurance teams must rethink how they respond to prior authorization requests. What if instead of a hard “No,” a representative said, “Let’s see what we can do together”? That’s not just good service. It lowers people’s tension and is good medicine. When insurance becomes a partner, not a process, people feel seen — not shuffled.

In the broader system, patient navigation — first championed by a physician who became an authority on race, poverty, and cancer — Harold Freeman, MD — shows that outcomes improve when people have support navigating the maze of care. Especially in underserved communities, navigators ensure that empathy is not dependent on privilege. It becomes a universal right.

Designing for Dignity

Empathy isn’t just something we express; it’s something we can design. We can build it into:

• The architecture of clinics that create calm, not chaos
• The approach we take in helping patients complete registration
• The way we train AI and LLMs to converse with respect
• The tone of insurance letters that minimize legalese and empathize with care
• The workflows that give nurses and doctors more time to connect

We must think of empathy not as reactive but as proactive. It must be embedded in systems, supported by policy, and measured by efficiency and experience. Empathy differentiates between treating a condition, focusing on a body part, and healing a person.

The System’s Soul

At its best, medicine is more than what we do — it is about how we do it. Empathy does not appear on a chart and is not coded into billing. But its absence is always felt, and its presence potentially transforms the entire care experience.

Empathy binds us back to our purpose, whether we are physicians in a clinic, nurses in an ICU, call center agents helping a customer navigate issues with a denied claim, or patient navigators walking with someone through a new diagnosis.

As we move into the future of AI, automation, digital health, and remote care, our most vital technology remains human connection. Our most critical clinical protocol is compassion.

Empathy is not a soft idea. It is medicine’s soul in action.

The post Empathy and Health Excellence — The Superpower of Care Delivery appeared first on Medika Life.

According to a Commonwealth Fund report, the US ranks last among high-income countries in healthcare access, efficiency, and equity. Our health system has vast potential and can achieve Moonshot-like outcomes, but it still struggles to address people’s day-to-day needs.

The world’s largest health ecosystem comprises five fundamental stakeholders — patients, payers, product innovators, policymakers, and providers. And while they should work in harmony, they remain primarily disconnected, operating in silos with financial performance as the measure of success. With the fear of economic failure nipping its leaders’ heels, the system prioritizes fiscal responsibility over patients’ healthy longevity. It leads to a “sick-are” over healthcare strategic mindset.

A System Disconnected

While medicine is a “team-support,” the health industry positions its sectors like boxers — each pitted against the other. The concept of a fragmented health system is not new. Nearly 20 years ago, Dr. Alain C. Enthoven, a renowned health economist, argued that the US health sector suffered from a fundamental lack of coordination and misaligned incentives, leading to inefficiencies that primarily burden patients.

In her book Fragmented, Ilana Yurkiewicz, MD, illustrates the real-world consequences of this disconnect. Patients often find themselves bouncing between specialists dedicated to one piece of their patient’s anatomy, grappling with conflicting medical advice, and navigating a bureaucratic maze that often results in disparate, delayed, or denied care.

Economic pressures fueling consolidations and layoffs have led major players to go slow on much-needed ambitious health information initiatives. The much-heralded digital transformation, which promises AI-driven operational efficiency, seamless data exchange, and improved patient outcomes, remains unrealized.

Meanwhile, patients are finding themselves trapped in a complex, hard-to-navigate medical maze where medical records are often inaccessible, treatment plans are inconsistent, payer decisions feel opaque, and pricing remains elusive. The effect is profoundly dehumanizing.

The Patient is Out of the Picture

Financial pressures outweigh the fundamental goal of healing, and the loss of patient focus and a significant decline in empathy remain the system’s most glaring obstacles. This absurd reality is captured in a satirical moment from Yes Minister, where a lawmaker appointed by the UK Prime Minister visits an award-winning hospital — shockingly operating without patients. While comedic, the scene reflects an all-too-real aspect of modern health systems. Administrative structures, insurance approvals, and reimbursement models dictate operations, often sidelining the very individuals who seek care and healing.

As economic priorities continue to reshape industry, hospitals that once promised solutions struggle to sustain themselves, leaving patients increasingly marginalized. While improving patient outcomes should be the central focus of government policymakers, they too often become secondary considerations.

As the US Congress considers budget decisions, cutting Medicaid state subsidies does not mean economically struggling patients will be denied urgent care. Instead, when they seek treatment in the ER, hospitals will absorb the cost. This shifts the financial burden, further straining healthcare systems already operating on razor-thin margins.

Doctor Burnout: Primary Symptom of a Broken System

Physicians enter medicine purpose-centered with a desire to heal, yet the system relentlessly applies administrative and financial pressures that shift their attention elsewhere. Many doctors experience burnout, driven by excessive paperwork, prior authorization hurdles, and unrealistic patient quotas. According to a Mayo Clinic Proceedings study, nearly 63% of physicians report signs of burnout, including emotional exhaustion and depersonalization.

Designed to streamline care, electronic medical records (EMRs) are still a significant source of frustration. Physicians spend hours dealing with complex interfaces rather than engaging with patients. The demand to see more patients in less time — dictated by billing and reimbursement structures — further erodes the doctor-patient relationship, leading to dissatisfaction on both sides.

A 2023 survey by the Primary Care Collaborative and the Larry A. Green Center found that 62% of primary care physicians report not having enough time to adequately meet patients’ needs, which impacts treatment and preventive care discussions.

This dissatisfaction manifests as a breakdown in communication. While effective dialogue between providers and patients across specialties and within the broader health ecosystem is essential for treatment and prevention, patients and physicians struggle to find time to connect.

Burnout is not simply a professional hurdle; it’s a crisis that directly affects patient outcomes. Overworked, exhausted doctors are likelier to make errors, experience lower job satisfaction, and even leave the profession altogether. If the system fails to address professional despair and its causes, the shortage of health professionals will only worsen, limiting access and compromising care.

The Business of Health Over the Health of People

While business considerations shouldn’t take precedence over people, the financial structures underpinning the health sector drive decision-making that deemphasizes people’s health. The silos within the health ecosystem exacerbate this issue, preventing a shared understanding of economic and operational realities, limiting coordinated action and shifting the focus away from the patient.

Insurers prioritize cost control without recognizing the pressures this places on providers. Pharmaceutical companies innovate without fully considering how reimbursement models shape prescribing behaviors. Policymakers create regulations with a limited understanding of their clinical innovation impact. This lack of cross-sector awareness perpetuates fragmentation and inefficiency, and patients ultimately pay the price.

Digital health companies, once hailed as the future of care efficiency and effectiveness, are struggling with financial sustainability, forcing many to pivot or shut down entirely. Biopharmaceutical companies triage drug development pipelines, looking for future medicines with a high probability of regulatory success rather than encouraging research that may fail but illuminate a pathway to even more significant discoveries. Again, it is the patient who pays the price.

The Cost of Failing to Invest in Care and Caring

There is enough blame to go around, and we must stop looking for a convenient villain. If we attack one piece of the ecosystem rather than look at the totality of our problem, we will fail to make meaningful changes.

We can’t throw our health system out and start from scratch; we must find a way to work within and through it effectively. The primary lever that will drive reform of the health system and improve its functioning is bringing everything back into empathetic focus, with the patient at the center of care. Whether we are payers, product innovators, policymakers or providers, we must ask if our actions are built on a foundation of empathy — from heartfelt “care.” First and foremost, we must cooperate in the service of the patient.

The health sector is an industry, but it must be more than that. At its core, it should recognize that we are always people — only sometimes patients. Yet, financial pressures have overtaken its fundamental purpose: healing. This system-wide disconnect erodes trust, drives up costs, and leaves too many without the care they need. Until the key players in the health ecosystem realign around a unified, patient-centered mission, fragmentation will persist, outcomes will fall short, and lives will remain at risk. The stakes are too high to accept anything less.

Unless we build on a foundation based on “how would I feel” empathy, our system will not be built to last. It will be structured to fail.

The post Business of Health: When Patients Become Secondary to the System appeared first on Medika Life.

As communication leaders and health executives, we must confront an uncomfortable truth: A significant segment of the American public harbors deep-seated resentment and frustration toward us. Some view Thompson’s murder with a sense of bizarre satisfaction, a stark indicator of how broken the relationship is between those who seek healing and the entities that are pledged to heal.

Despite its role in driving unmatched technological and scientific advancements and its world-class roster of skilled and dedicated professionals, the American health ecosystem is increasingly frustrating for patients who are constantly challenged to access and pay for care. A 2022 KFF survey revealed that 41 percent of Americans carry some form of healthcare debt. This statistic paints a grim picture of household pocketbooks emptied because of poor coverage and high costs.

That’s only the tip of the iceberg. Even those with private and employer-sponsored insurance face a labyrinth of frustrations. High premiums strain household budgets, pushing some into medical poverty. Costly co-payments discourage those who need it from seeking preventive care. Confusing coverage rulings, such as step-through therapy or non-medical switching, are deeply frustrating and leave many who need medications in limbo. Seemingly arbitrary denials of care, which are devastating to cope with when fighting serious illness, provide life’s most stressful moments.

The outcome? There’s a growing body of consumers who feel they’ve been abandoned by a system meant to protect them, a system that they pay a significant amount of every paycheck to support, that will not support them when needed. The contract, in their experience, has been broken. When coverage denials arise and bills pile up, people with illnesses often find themselves at the mercy of collection agencies, adding frightening financial insult to physical injury and illness.

A public cry for systemic change

The view of the shooter as a folk hero reflects the public’s deep frustration with a system that makes managing care, accessing services and understanding payment obligations needlessly complex. This is leading to a significant shift in public opinion; a recent Gallup poll indicates a substantial upswing in support for government-insured universal health coverage, which suggests that Americans have an appetite for a radical overhaul of our health system. The industry must recognize that public outcry is kindling fires that fuel changes in public policy.

In the health industry, we often claim that the patient is at the center of care; that naïve Band-Aid should be ripped off. The public reaction to Thompson’s death provides us with an essential opportunity to recognize that we have lost the trust of many of the people we supposedly serve. It must be a catalyst for health companies—innovators and insurers—to reassess their approach to patient care and public trust.

Profitability and service to the patient aren’t two separate outcomes. Investing in interventional care and providing that care are also inextricably intertwined. There are several key recommendations the industry should consider at this moment:

Prioritize transparency: Simplify policy language and coverage explanations, which currently make it difficult for patients to understand their insurance and impossible to make decisions about their care. They feel the ground is shifting under their feet, so make it clear what is covered and why specific treatments might be denied.

Enhance the customer experience: Invest in solid support systems that guide patients through the complexities of their care options. How can apparel chains like Nordstrom have better customer service than the health industry? Shouldn’t our bodies be entitled to a level of customer service that is at least the equivalent to that of the companies that clothe us? Insurance companies must recognize that customer service is one of the most important parts of their business and not an afterthought.

Embrace preventive care: Our system prioritizes sick care over healthcare. To promote better health—while helping to keep insurance company and patient costs lower—it’s time to shift focus from stressful reactive treatment to supporting proactive health management. This can improve patient outcomes, keep people from suffering from progressive illnesses and reduce long-term costs.

Advocate for systemic reform: Health is not a partisan issue, and the industry must work proactively with patients and policymakers to address the root causes of health inequality and inaccessibility. We can make social impact an integral part of our business models and channel a percentage of profit to address health equity challenges that cost the most vulnerable right now and will cost the industry and taxpayers significantly further down the road.

Humanize the industry: Communications is part of the cure, and health companies, particularly insurance companies, can and must do better when sharing information and narratives with patients. We must share stories—within HIPPA guidelines—of how lives can be improved and saved, and we must do so regularly, not only when the industry’s reputation is threatened. Take the time to speak to patients, communicate how things work and build trust.

Communication as a bridge to trust

As communication professionals, we have a crucial role in this transformation. Our task must not simply be about defending reputations. We are responsible for facilitating a dialogue between health providers and the public they serve.

To do this, we must craft narratives that emphasize the human element of healthcare and facilitate forums for patients to voice their concerns and to be heard to foster fruitful discussion. Our communications expertise should not simply be leveraged to highlight initiatives that demonstrate a company’s commitment to putting patients first; it must be employed to educate the public on how to navigate the complexities of health delivery, to advocate for simplification of communications and to executive information campaigns that help patients to access the care they must have.

A new vision for the American health system

Brian Thompson’s murder is a tragedy that should never have occurred. There’s no justification for violence. At the same time, we must not let this moment pass without reflection and action.

It’s time for the health industry to recommit to its core mission: to prevent illness and to heal. This commitment must be more than a PR strategy. It must be the driving force behind every policy, every customer interaction and every decision. By placing people at the center of our efforts, we demonstrate that the US health system’s primary interest is in the well-being of those it serves.

The path ahead is challenging; we must walk it together—industry leaders, health providers, life science innovators, policymakers and patients alike. As we move forward, we in the industry must note that healing extends beyond the physical; it encompasses the restoration of faith in a system that has the great potential to protect and nurture all Americans, regardless of their location and bank account size—one that inspires confidence rather than despair and rage.

It’s time for the industry to lead by example, to show through deeds that the health and trust of the American people are its most valuable assets. Only through collective effort and a shared vision centered on ensuring “medicine is for the people” can we achieve that long-awaited transformation. Thompson’s tragic death—and his family’s enduring pain—must be a catalyst for that transformation. It’s not about saving face; it’s about saving lives and restoring the soul of the American health system.

The post A Shock to the U.S. Health Industry appeared first on Medika Life.

Not to take anything away from the Senator’s apparent concern for his constituents’ real, valid frustration with the health system, but is his villain the right one? Is it a fundamental misreading of the facts of the US health ecosystem to believe that there is any one villain in the system at all? The real, underlying reason that the US health system is so fragmented is that the system itself is the problem. And, as it must be, the system will be the source of any viable solution that makes navigating less challenging and more holistically unified.

Stop Blaming Individual Sectors — Look at the Aggregate

High drug prices are just one symptom of a health ecosystem already becoming increasingly fragmented several decades ago. The problem was well-established and recognized when economist Dr. Alain C. Enthoven wrote about it in the American Journal of Managed Care more than a decade ago, positing that inefficient allocation of resources negatively impacted quality, cost of care and medicines, and patient outcomes.

Since then, little has changed. In 2016, FINN Partners released a survey showing that the fragmented health ecosystem was placing an ever-greater burden on patients, the people the system is supposed to protect and serve — and was increasingly failing. Eight years later, the results of this survey will not have changed significantly.

For decades, payers, patients, policymakers, product innovators, and providers turned a blind eye to fragmentation. And while policymakers prefer to spotlight a popular villain — drug cost — the relentless search for villains won’t fix fragmentation. If we attack one piece of the ecosystem rather than look at the problem, we will fail to make meaningful change. While putting pharmaceutical company CEOs under the glare of the Senate HELP spotlight may provide a tremendous election-year photo-op, bipartisan grandstanding is antithetical to addressing the health system’s continued splintering.

If the System Were a Patient with Multi-System Failure, Would We Treat Only One Organ?

We now know beyond a doubt that the health system is fragmented and has a cost impact. It is time to move from this era of fragmentation into the “post-fragmentation” period. Rather than finger-pointing and finding scapegoats, what’s needed is a fuller understanding of how the system works — and fails to work — for the patient. This requires looking at the full picture objectively, without accusation, to understand better how the different players in the system can work together to support the same goal: a health system in which the patient, not the system itself, is the health system’s true beneficiary.

It’s a fact: prescription drug prices in the United States are higher than in other nations, averaging 2.78 times those seen in 33 different countries, according to the February 2024 RAND report. But are pharma companies the sole cause of this patient burden and health-system chaos? Absolutely not: drug costs comprise about 11 percent of the total $4 trillion in US health expenditures. In reality, provider and hospital services total almost half of US health spend (31.4 percent and 20.3 percent respectively).

Fragmentation Adds to Patient Care Burdens and Costs

Fragmentation leads to out-of-control spending across the system. According to a 2018 Commonwealth Fund study, Medicare recipients “with three to four chronic conditions and highly fragmented care are 14 percent more likely to visit the emergency department, and six percent more likely to have a hospital admission.”

If the US health system were a publicly traded corporation, this hemorrhaging of cash would have been decisively stopped years ago. Taken together, the $4 trillion in annual US healthcare costs can be laid on the doorstep of nearly every player in the ecosystem, from insurance companies to PBMs, pharmacies, pharmaceutical companies, government, hospitals, and venture capital, to name a few — even endless consumer demand and neglected preventive care.

Operating with a business-as-usual approach will carry steep costs in money and lives. When the system fails to engage people proactively with heightened risk for heart disease, cancer, diabetes, and other non-communicable illnesses, when it denies patients diagnostic procedures ordered by their physicians, when it shifts patients from working medications to substitute therapies due to a non-medical switch decision, curiously, some parts of the system benefit to the detriment of patients.

These situations shouldn’t be, as the consequences of the current line and the decisions they reward can be dire, leading to rising costs, diminished patient care, and even death. Ultimately, the chaos around care delivery comes from considering patients a necessary fly in the system’s ointment. The patient is not the health system customer. The system is a customer unto itself.

Can We All Focus On Why the System Exists — To Heal Patients?

We recognize the health system’s failings but must also identify its strengths and potential for improvement. This will allow us to reorient our thinking and ask, “Now, what do we do to put the patient back into focus as the ultimate customer and the preferred beneficiary of the system?”

Stanford Physician Ilana Yurkiewicz, an internist, hematologist, and oncologist, in her book Fragmented: A Doctor’s Quest to Piece Together American Health Care, published by W. W. Norton, argues that it’s actually fragmentation that’s the central failure of health care today, resulting in a system that uses more than twice the economic resources other developed nations dedicate toward health and which results in poorer life expectancy outcomes:

“There’s an unspoken assumption when we go to see a doctor: the doctor knows our medical story and is making decisions based on that story. But reality frequently falls short. Medical records vanish when we switch doctors. Critical details of life-saving treatment plans get lost in muddled electronic charts. The doctors we see change according to specialty, hospital shifts, or an insurer’s whims.”

No longer are we debating whether the system is fragmented or not. We must shift our mindsets and drop the mistaken belief that identifying bad players in the ecosystem will fix the problem. With ecosystem fragmentation as the diagnosis, what is the treatment path to better management? This is where “Health System Kinetics” (HSK) enters. HSK fosters collaboration and leverages health information technologies — AI, ChatGPT, GenAI, and LLMs — to create an eco-dynamic that prioritizes people’s well-being and works toward longer, healthier lives.

The Health System is Greater Than Its Sector Parts — Study its Kinetics

Health System Kinetics objectively studies factors and sector-to-sector relationships influencing individual and collective health outcomes. It includes biological, environmental, social, and economic determinants of health. Understanding health system kinetics will allow the health system to evolve for the better, benefiting its stakeholders and addressing gaps and inefficiencies in people’s care by fostering a proactive, positive approach.

Understanding why fragmented care is a system-wide illness is a starting point we passed long ago. Looking at the health ecosystem as an ever-changing aggregate — kinetics — rather than separate sectors at fault is the opportunity to move beyond the present chaos.

Fragmentation goes beyond the left hand, not knowing what the right is doing. Too often, it means that the left hand won’t acknowledge the right hand’s very existence. While rising costs concern everyone, it’s essential to keep our eye on the goal of keeping people healthier at home, out of the hospital, and, if possible, far away from illnesses. To do that, we must address the misalignment of incentives and lack of coordination in the health ecosystem.

Applying Health System Kinetics will allow us to understand better how we can do this to provide better patient care, reduce health professional burnout, and give patients with chronic conditions greater attention. The objective study of the interconnectedness of the parts of the healthc system will promote a better understanding of how these components work together now — and how they can be changed to work better together in the future. Failing to take this approach means we won’t see meaningful change, and that’s not an option.

Do Not Let the Virus Kill its Host — the Health System

We have diagnosed the illness that plagues our health system; it’s a virus called fragmentation. It’s time to examine our biases, behaviors, and business goals. The primary mission is to recognize that we are people — sometimes patients — all seeking to enjoy a healthier life. Suppose fragmentation is the wall that separates us from better access to care. In that case, health professionals in every ecosystem sector can be empowered to pursue their calling with passion and tear down that wall.

Looking for a villain in the health ecosystem, something lawmakers have been doing for the last several election cycles, may be suitable for campaigning but not for progress — not for continued innovation and patient care. Progress can only be achieved when we get past the mindset of the period in which we have been — the period of acknowledging the system is fragmented — and move into the post-fragmentation era, in which we view the system through the lens of health kinetics and eco-dynamics.

When we look at and understand how all parts of the system work together — or fail to –we enter an era in which we no longer debate who’s to blame. Proper understanding will allow us to compromise, adjust our aims, improve our practices, and finally, make changes that remove the health system as its own beneficiary, replacing it with the patient as the system’s customer.

[Special thanks to John Bianchi for his review of this health policy economics article that shifts the conversation from sector-to-sector blame to a forward-looking perspective; to industry friend and mentor John Nosta for encouraging me to put these thoughts into publication and to Dr. Dean and Anne Ornish, pioneers in preventive and consumer empowered health and co-founders of Ornish Lifestyle Medicine.]

The post We Know the Health Ecosystem is Fragmented, Resulting in Rising Costs and Poorer Patient Outcomes, But What Are We Doing About It? appeared first on Medika Life.

Amid rising inflation, annual family premiums for employer-sponsored health insurance climbed 7% on average this year to reach $23,968, a sharp departure from virtually no growth in premiums last year, the 2023 benchmark KFF Employer Health Benefits Survey finds.

On average, workers this year contribute $6,575 annually toward the cost of family premium, up nearly $500 from 2022, with employers paying the rest. Future increases may be on the horizon, as nearly a quarter (23%) of employers say they will increase workers’ contributions in the next two years.

Workers at firms with fewer than 200 workers on average contribute nearly $2,500 more toward family premiums than those at larger firms ($8,334 vs. $5,889). In fact, a quarter of covered workers at small firms pay at least $12,000 annually in premiums for family coverage.

This year’s 7% increase in average premiums is similar to the year-over-year rise in workers’ wages (5.2%) and inflation (5.8%). Over the past five years, premiums rose 22%, in line with wages (27%) and inflation (21%).

Among workers who face an annual deductible for single coverage, the average this year stands at $1,735, similar to last year. The average deductible amount has increased 10% over the last five years and 53% over the last ten years.  Workers at small firms (under 200 workers) on average face much larger deductibles than workers at larger firms ($2,434 vs. $1,478).

The modest rise in deductibles may reflect employers’ perceptions about the burden of cost-sharing on workers.  More than half (58%) of employers say that their workers have at least a moderate level of concern about the affordability of their plan’s cost-sharing requirements.  

“Rising employer health care premiums have resumed their nasty ways, a reminder that while the nation has made great progress expanding coverage, people continue to struggle with medical bills, and overall the nation has no strategy on health costs,” KFF President and CEO Drew Altman said.

Almost 153 million Americans rely on employer-sponsored coverage, and the 25th annual survey of more than 2,100 small and large employers provides a detailed picture of the trends affecting it. In addition to the full report and summary of findings released today, the journal Health Affairs is publishing an article with select findings online. The article will also appear in its November issue.

Some Large Firms Do Not Cover Legal Abortions; Others Do But with Restrictions

In the wake of the Supreme Court’s June 2022 decision that ended the federal constitutional right to abortion, states have adopted a range of new laws to prohibit or severely restrict access to abortion, creating challenges for large employers with workers in multiple states.

Among all large firms (with at least 200 workers), one in ten (10%) say that their largest plan does not cover legal abortions under any circumstances. An additional 18% say they only cover legal abortions under limited circumstances, such as in cases involving rape, incest, or health or life endangerment.

In contrast, nearly a third (32%) of large firms say they cover legal abortions in most or all circumstances. Another four in ten (40%) say they were unsure of their plan’s abortion coverage, potentially because their policies were in flux or they were unaware of the details.

With abortion banned or severely limited in some states, 7% of large employers say that they provide, or plan to provide, financial assistance for travel expenses for enrollees who have to go out of state to obtain a legal abortion. Very large employers (with at least 5,000 workers) are most likely to provide, or plan to provide, such travel reimbursements (19%).

Concerns Persist About Adequacy of Mental Health and Substance Use Networks

Among large employers (with at least 200 workers) that offer health benefits to at least some workers, the vast majority (88%) say their plan has enough primary care doctors to provide timely access for enrollees. Substantially fewer say the same about their mental health (59%) and substance use condition (58%) networks.

Nearly one in five (18%) of large offering firms say that they took steps in the past year to increase the number of mental health providers in their largest plan’s network. This includes 44% of the largest employers (with at least 5,000 workers).

On the other hand, one in five (21%) of large offering employers say their plan has limits on the number of covered mental health services, potentially restricting access for enrollees with long-term needs.

“For several years now, the survey has shown that many large employers do not believe that their networks have enough mental health providers to provide timely access to care. In 2023, many large employers, including nearly half of the largest employers, say that they are taking steps to better meet enrollees’ needs,” said Gary Claxton, a KFF senior vice president and director of the Health Care Marketplace Project, the lead author of the study and also of the Health Affairs article.

Other findings include: 

• Offer rate. Nearly all employers with at least 200 workers offer health benefits to at least some workers, though smaller firms are increasingly less likely to offer health benefits as they get smaller. For example, 83% of firms with 10 to 199 employees offer health benefits to at least some of their workers, while just 42% of firms with three to nine workers do so.
• Dental, vision and long-term care insurance. Among firms offering health benefits, most also offer separate dental coverage (91%) – double the share that did so in 2010 (46%). Most also offer vision (82%) insurance, also up sharply since 2010 (17%). Fewer offer long-term care insurance (26%).
• Coverage for gender-affirming surgery. Among employers with at least 200 workers, 23% cover gender-affirming survey in their largest health plan. More than a third (37%) say they do not cover such surgeries, while a large share (40%) are not sure about such coverage. Among the largest firms (at least 5,000 workers), nearly two thirds (62%) cover gender-affirming surgery, many of which expanded the benefit in the past two years.
• Centers of Excellence. About one in five (19%) offering employers with at least 200 workers say their plan includes a “center of excellence” program for specific services, either limiting enrollees to a narrower group or providers or offering lower cost-sharing for doing so. Among these firms, 22% have introduced a new center of excellence program within the last two years. Among firms with a center of excellence program, 45% had a program for joint replacement, 42% for back or spine surgery, 31% for bariatric surgery, 30% for mental health, and 28% for substance use disorders.

Methodology

KFF conducted the annual employer survey between January and July of 2023. It included 2,133 randomly selected, non-federal public and private firms with three or more employees that responded to the full survey. An additional 2,759 firms responded to a single question about offering coverage. For more information on the survey methodology, see the Survey Design and Methods Section.

ABOUT KFF:

KFF is the independent source for health policy research, polling and news.

ABOUT HEALTH AFFAIRS:

Health Affairs is the leading peer-reviewed journal at the intersection of health, health care, and policy. Published monthly by Project HOPE, the journal is available in print and online. Late-breaking content is also found through healthaffairs.org, Health Affairs Today, and Health Affairs Sunday Update.

Project HOPE is a global health and humanitarian relief organization that places power in the hands of local health care workers to save lives across the globe. Project HOPE has published Health Affairs since 1981.

The post Benchmark KFF Survey: Annual Family Premiums for Employer Coverage Rise 7% to Nearly $24,000 in 2023 appeared first on Medika Life.

Sally Nix was furious when her health insurance company refused to pay for the infusions she needs to ease her chronic pain and fatigue.

Nix has struggled with a combination of autoimmune diseases since 2011. Brain and spinal surgeries didn’t ease her symptoms. Nothing worked, she said, until she started intravenous immunoglobulin infusions late last year. Commonly called IVIG, the treatment bolsters her compromised immune system with healthy antibodies from other people’s blood plasma.

“IVIG turned out to be my great hope,” she said.

That’s why, when Nix’s health insurer started denying payment for the treatment, she turned to Facebook and Instagram to vent her outrage.

“I was raising Cain about it,” said Nix, 53, of Statesville, North Carolina, who said she was forced to pause treatment because she couldn’t afford to pay more than $13,000 out of pocket every four weeks. “There are times when you simply must call out wrongdoings,” she wrote on Instagram. “This is one of those times.”

Prior authorization is a common cost-cutting tool used by health insurers that requires patients and doctors to secure approval before moving forward with many tests, procedures, and prescription medications. Insurers say the process helps them control costs by preventing medically unnecessary care. But patients say the often time-consuming and frustrating rules create hurdles that delay or deny access to the treatments they need. In some cases, delays and denials equal death, doctors say.

That’s why desperate patients like Nix — and even some physicians — say they have turned to publicly shaming insurance companies on social media to get tests, drugs, and treatments approved.

“Unfortunately, this has become a routine practice for us to resort to if we don’t get any headway,” said Shehzad Saeed, a pediatric gastroenterologist at Dayton’s Children’s Hospital in Ohio. In March, he tweeted a photo of an oozing skin rash, blaming Anthem for denying the biologic treatment his patient needed to ease her Crohn’s disease symptoms.

In July, Eunice Stallman, a psychiatrist based in Idaho, joined X, formerly known as Twitter, for the first time to share how her 9-month-old daughter, Zoey, had been denied prior authorization for a $225 pill she needs to take twice a day to shrink a large brain tumor. “This should not be how it’s done,” Stallman said.

The federal government has proposed ways to reform prior authorization that would require insurance companies to provide more transparency about denials and to speed up their response times. If finalized, those federal changes would be implemented in 2026. But even then, the rules would apply only to some categories of health insurance, including Medicare, Medicare Advantage, and Medicaid plans, but not employer-sponsored health plans. That means roughly half of all Americans wouldn’t benefit from the changes.

The 2010 Patient Protection and Affordable Care Act prohibits health insurance plans from denying or canceling coverage to patients due to their preexisting conditions. AHIP, an industry trade group formerly called America’s Health Insurance Plans, did not respond to a request for comment.

But some patient advocates and health policy experts question whether insurers are using prior authorization as “a possible loophole” to this prohibition, as a way of denying care to patients with the highest health care costs, explained Kaye Pestaina, a KFF vice president and the co-director of its Program on Patient and Consumer Protections.

“They take in premiums and don’t pay claims. That’s how they make money,” said Linda Peeno, a health care consultant and retired Kentucky physician who was employed as a medical reviewer by Humana in the 1980s and later became a whistleblower. “They just delay and delay and delay until you die. And you’re absolutely helpless as a patient.”

But there’s reason to hope things may get marginally better. Some major insurers are voluntarily revamping their prior authorization rules to ease preapproval mandates for doctors and patients. And many states are passing laws to rein in the use of prior authorization.

“Nobody is saying we should get rid of it entirely,” said Todd Askew, senior vice president for advocacy at the American Medical Association, in advance of the group’s annual meeting in June. “But it needs to be right-sized, it needs to be simplified, it needs to be less friction between the patient and accessing their benefits.”

Customers are increasingly using social media to air their complaints across all industries, and companies are paying attention. Nearly two-thirds of complainants reported receiving some sort of response to their online post, according to the 2023 “National Consumer Rage Survey,” conducted by Customer Care Measurement & Consulting in collaboration with Arizona State University.

Some research suggests companies are better off engaging with unhappy customers offline, rather than responding to public social media posts. But many patients and doctors believe venting online is an effective strategy, though it remains unclear how often this tactic works in reversing prior authorization denials.

“It’s not even a joke. The fact that that’s how we’re trying to get these medications is just sad,” said Brad Constant, an inflammatory bowel disease specialist who has published research on prior authorization. His work found that prior authorizations are associated with an increased likelihood that children with inflammatory bowel disease will be hospitalized.

Saeed said the day after he posted the picture of the skin rash, the case was marked for a peer-to-peer review, meaning the prior authorization denial would get a closer look by someone at the insurance company with a medical background. Eventually, the biologic medicine Saeed’s patient needed was approved.

Stallman, who is insured through her employer, said she and her husband were prepared to pay out of pocket if Blue Cross of Idaho didn’t reverse the denial for the drug Zoey needed.

Bret Rumbeck, a spokesperson for the insurer, said Zoey’s medication was approved on July 14 after the company consulted an outside specialist and obtained more information from Zoey’s doctor.

Stallman posted details about the ordeal online only after the insurer approved the drug, in part, she said, to prevent them from denying the treatment again when it comes up for a 90-day insurance review in October. “The power of the social media has been huge,” she said.

Nix had been insured by Blue Cross Blue Shield of Illinois through her husband’s employer for almost two decades. Dave Van de Walle, a spokesperson for the company, did not specifically address Nix’s case. But in a prepared statement, the company said it provides administrative services for many large employers who design and fund their own health insurance plans.

Nix said an “escalation specialist” from the insurance company reached out after she posted her complaints on social media, but the specialist couldn’t help.

Then, in July, after KFF Health News contacted Blue Cross Blue Shield of Illinois, Nix logged in to the insurer’s online portal and found that $36,000 of her outstanding claims had been marked “paid.” No one from the company had contacted her to explain why or what had changed. She also said she was informed by her hospital that the insurer will no longer require her to obtain prior authorization before her infusions, which she restarted in late July.

“I’m thrilled,” she said. But “it just should never have happened this way.”

The post Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials appeared first on Medika Life.

We live in a very exciting time! Alzheimer’s medications that are more promising than past drugs are starting to hit the shelves, with others on the way. Eli Lilly’s new daratumumab medication has been suggested to slow the progression of early Alzheimer’s by up to 35%. So if it took someone five years to progress to more serious Alzheimer’s without medication, this could slow it, so it could instead take seven years, meaning more years being more present with one’s family. Lecanemab (Leqembi), from Eisei and Biogen, was also found to reduce cognitive decline, keeping our parents or ourselves fully present as we traverse life’s journey together!

In this article, I will talk about why these drugs offer society hope yet will also cause a big problem, at least in the short term (i.e., until generics become available when the drugs’ patents expire). As for my background, I earned my M.D. in the United States to soon earn my Ph.D. in Canada, focusing on Genetics. Today, I work as a postdoctoral scientist at Massachusetts General Hospital, studying the genetics of Alzheimer’s disease. In my medical training, I have seen the tragedy that can happen to people’s parents or themselves as they face newly diagnosed dementia and late-stage disease.

To be clear, these medications are a good thing. They could help many of those around us, whether a parent, sibling, or ourselves. Dementia is a horrible disease; until now, not much could be done about it. A family member is diagnosed with the disease in the office and told that they are showing signs of this illness and that very little can be done to help them. Over time, their personality changes, and they slowly become less like themselves daily, aware of what is happening.

This can cause significant distress for those with this illness and their family and friends. We spend years with these people. We are forced to watch, unable to make a difference, as they lose their ability to function and lose who they are. These medications could slow these changes, finally offering some semblance of hope for those with these diseases.

As with any medication, these drugs do not come without risks. One in four people who received Leqembi had a “transfusion reaction,” which in most people means that they may have had redness and swelling in the arm they received the medication. While such reactions can be severe, causing one’s airway to close up in an anaphylactic reaction, these responses are generally uncommon. Some individuals who received Leqembi or Donanemab experienced swelling in their brain, known as cerebral edema. While not necessarily a problem, in that it does not necessarily produce symptoms, one in four people who took Donanemab developed this swelling, one of four of which had symptoms. So if we considered a group of 1000 people who took this drug, using the study’s results, about 60 in 1000 could experience headaches or confusion. Some of these 60 individuals may develop bleeding in their brains. Around two could die from the swelling or bleeding. While concerning, 940 of these hypothetical 1000 people had no side effects. Even if you took this med and experienced side effects, you could be sure that your doctor would do everything they could to keep you safe, including discontinuing the medication that often resolves adverse effects.

So it sounds like my opinion is that these drugs sound promising. Why the doom and gloom article title? This is because these are or will be very expensive drugs. The price for a single person to receive enough Leqembi for a single year is forecasted to be $26,500. While Donanemab does not yet have an official cost, it is predicted to be over $26,000 annually. Think about that amount of money for a moment. The federal poverty line for a family of four, which could include a couple, a child, and a grandparent, is $30,000. More than one in 10 people in the United States are impoverished and struggling to make ends meet. This number is likely even higher, considering you do not have to be impoverished to have financial difficulty. What would happen if a couple’s loving grandmother or grandfather started showing signs of dementia?

While the elderly are entitled to Medicare, would Medicare cover such an expensive drug when it has to care for the entire country’s elderly population? Even if it pays for it, how much of it? After consulting physician colleagues of mine, we think it is unlikely that Medicare as is would pay this much. It would be great if they did, but there are likely not enough Medicare dollars to permit this.

Families could face impossible decisions or immense stress once these medications are more broadly available, and they have hope in front of them, yet this hope is financially inaccessible. While some private insurance may help pay for these cutting-edge treatments, perhaps with Medicare offering a small contribution, insurance is expensive, and we sadly do not all have health plans that enable us to not think about how we are going to make managing our health work, alongside taking care of supporting children, family, and parents.

There is also the concern that these medications may offer more benefit to those of certain ancestral groups, as reported by Reuters. This was not because the study’s designers or the company sought to exclude non-whites. For medical research to be approved, generally, one must communicate how the research will benefit a more diverse group. Describing how people are recruited into appropriately designed clinical trials and why medications may help people of European descent more than those of African descent is its own article, so I will not touch on this here. This is important because non-whites have higher rates of Alzheimer’s and have historically had less access to healthcare resources.

Such a financial predicament is not unique to these upcoming new medications (or healthcare in general in the United States). Research and development of new medications often cost over $2 billion when a new treatment is available for the general public. Companies need to give treatments a price that enables them to make up for what they spent and enable their other projects, which can also provide hope for better health management. While this approach is understandable (companies need to avoid going bankrupt. Even non-profits need to do that), it can still limit our access to treatments that could save or improve our lives.

The only fix that could address these issues is legislation, which the American Medical Association is consistently striving to improve people’s health in the United States, including driving healthcare reform and expanding (versus cutting) Medicare coverage. Your doctors are not just treating you in the office. They are going to Washington, D.C., and suffering the stresses of politics to improve your lives!

In conclusion, we have reasons to be optimistic about these new drugs. We are also facing the same problems that we have in the past, with promising treatments often being beyond the reach of those with less financial resources and those who have historically had limited access to treatments that could mitigate suffering.

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