Complex insurance systems cause confusion and delays, blocking timely access to medications and services. Many patients abandon treatment due to lengthy approvals, high costs, or unclear benefits. This can result in underdosing or medication sharing, ultimately resulting in frustration for patients and providers as well as worse health outcomes.
Patients with diabetes with changing or no insurance coverage (10–20% of the population).
Pharmacists and clinics burdened by heavy administrative workloads.
Most rural primary care clinics lack funding for dedicated staff to help patients navigate medication coverage and follow-up. This challenge is worsened by siloed, incompatible systems used by front desk staff, providers, and pharmacies. For example, a clinic’s electronic health record may not connect with the state Medicaid formulary or the pharmacy’s software, preventing real-time verification of medication coverage and cost. Without centralized tools, providers rely on workarounds like calling insurers, using staff memory or paper formularies, or subscribing to paid services. These methods are unreliable, time-consuming, and costly. Some clinics even charge patients $25–$30 for each prior authorization attempt, regardless of the outcome.
In most cases, providers prescribe based on best guesses, and patients only discover coverage issues at the pharmacy—leading many to leave without their medications when faced with unexpected out-of-pocket costs. Some providers support their patients by using personal time to search for low-cost generics on websites like GoodRx or Amazon, relying on charity programs, or depending on staff with institutional knowledge. However, this expertise is often lost with staff turnover and is not scalable or sustainable.
NEEDS STATEMENT:
Develop a simplified, unified system for prescribing and securing prior authorizations for advanced diabetes therapies (e.g., GLP-1s, insulin, CGMs).
REQUIREMENTS:
Track authorizations to decrease reliance on manual check-ins.
Integrate auto-enrollment in financial assistance programs like 340B.
ADDITIONAL CONSIDERATIONS:
Programs like the $35 insulin cap often exclude Medicare and Medicaid beneficiaries, limiting their effectiveness for those most in need. A novel system should flag similar exceptions in coverage should be flagged and suggest alternatives.
Monitor supply availability internally or in local pharmacies prior to selecting between similar treatments.
Consider ways to synthesize institutional knowledge about care access programs and cheaper alternatives that are independent of employee attrition.
