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Mapping the Messy Middle - Blog

Mapping the “Messy Middle” to Support Patients Through Frequent Payer Transitions

Mapping the Messy Middle - Blog

Authors: Vivian DeWoskin, General Manager, Commercial, Komodo Health; Kevin Francis, Partner, Real-World Evidence, Trinity Life Sciences; Jennifer Parr, Principal, Patient Centricity, Primary Market Research, Trinity Life Sciences

In the patchwork system of U.S. health insurance, changes in age, health, or employment can all force changes in healthcare coverage. With a mix of public programs such as Medicare and Medicaid and private or employer-based payer programs, navigating changes in healthcare coverage can be a challenge.

How frequently does this happen? According to a 2016 report, about half of Americans surveyed had changed health insurance plans in the past three years. The average U.S. worker holds 12 different jobs in their lifetime, and data from the Bureau of Labor Statistics in 2019 suggested that at least two million workers and their families lost their employer-sponsored plans or transferred to new ones every month. More recently, policy changes in response to COVID-19, including a special enrollment period and new subsidies and incentives, encouraged many Americans to sign up or switch plans. Nearly 940,000 people registered between February 15 and April 30, 2021. 

The “messy middle”  

Switching from one health insurance plan to another can be messy for patients, in large part because insurers set their own benefits and cost structures: there is no standard package. Consequently, patients may experience gaps in care, or changes in access to healthcare providers (HCPs) or treatments when transitioning between payers. They could face new requirements for step therapy or prior authorization that they had met in their previous health plan, or limitations on medication quantity or treatment frequency. This could cause critical delays in progress for those combating chronic conditions; in a recent survey of people with migraine, 87% had experienced prior authorizations, 82% medication dose limits, and 77% step therapy. They might be hit with unexpected costs at the point of care, if deductibles and out-of-pocket maximums reset, or if copays and coinsurance amounts are different.

For those managing chronic or progressive conditions, the “messy middle” can have particularly serious implications. 

Patients with schizophrenia, for example, may age out of coverage under their parents’ insurance or lose their jobs as the disease progresses, causing them to transition from commercial payers to Medicaid. This transition period represents a risk, as switching medications and providers is extremely disruptive to this vulnerable population. 

Amyotrophic lateral sclerosis, or ALS, involves progressive decline in patients’ mobility, capacity to care for themselves, and ability to perform their jobs. As a result, patients often transition to Medicare from employer-sponsored plans, which can affect their access to the treatments or equipment they may need along the clinical continuum. 

Untangling the confusion  

Transitions are messy from a data perspective, too. Historically, it’s been difficult to connect patient data from different payers, obstructing our view of this part of the patient experience. Komodo’s Healthcare Map™ removes that obstacle by linking patient-level data from myriad sources, presenting a longitudinal view of the entire patient journey, whether care was received in-network, out-of-network, or through a specialist, urgent care center, or retail clinic.

Mapping the “messy middle” provides insights about the individual patient journey, enabling stakeholders across the healthcare system — HCPs, payers, pharmacies, and manufacturers — to develop targeted intervention and engagement strategies.

The Healthcare Map gives us a unique opportunity to follow patients as they navigate the “messy middle” to understand and address the challenges they face. For example, diabetes is notoriously difficult to manage and can have debilitating outcomes that lead to frequent transitions in care involving both HCPs and payers. Patients with Type 2 diabetes were insured by an average of 2.4 health plans within six years, according to a recent analysis of open and closed patient medical encounters and prescriptions from 2015–2020 using Komodo‘s Healthcare Map. These transitions can push patients backward in treatment if the new plan covers different drugs or involves utilization management features such as prior authorization or step therapy. 

As healthcare stakeholders seek to help patients overcome these hurdles, insights about the longitudinal patient journey can inform their efforts. For example, many health plans offer transition of care benefits that allow patients to continue receiving services from their current HCPs, even if they are out of network, during a specified time window. Similarly, drug- and device-makers may offer bridge programs to mitigate potential lapses in therapy and patient assistance or co-pay programs to improve access. 

Komodo Health and Trinity Life Sciences recently announced a partnership focused on unlocking insights like these to drive smarter business strategies for pharma, biotech, and med-tech companies. Trinity’s EvidenceFirst, a suite of real-world evidence offerings, leverages Komodo software to draw from the Healthcare Map and put real-world data in context. 

By cultivating this deeper understanding of patient journeys, we can better meet patients’ needs, improve outcomes, and ultimately reduce the global burden of disease. To truly understand and support patients, we need to understand transitions across the entire care continuum — or map the “messy middle.”

Learn more about the power of data to support healthcare innovation in ”Unlocking the Opportunities Hidden in Healthcare Data.“

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