The Black Hole of Specialty Healthcare

In a hospital setting there are two major shift changes, or what I call the changing of the guards.?At 7:00 a.m., your night nurse team meets with the day nurse team and there’s about an hour that they huddle and bring in/or write on a white board in your room who the replacement nurse is, who now knows all the intimate details of your case so they can swoop in and just take over your care.?The same happens at 7:00 p.m.??

Separately, every year our entire healthcare system allows what is called a patient open enrollment period.

During this open enrollment period, anyone can change their employee or state provided healthcare coverage, your employer included.?Sometimes during this period, the company who employs you will choose a different pharmacy benefit manager for your prescriptions, including biologics. Other times the health insurance company themselves purchase or sell or team up with a different pharmacy benefit manager.

Optum and CVS/Caremark are examples of pharmacy benefit managers, or a PBM as an acronym.?There are others if you search online. They typically have a separate area that services specialty medications, such as biologics.?Why is this type of change important for patients??Why should you even care? Don’t they have a process like they do in a hospital? Not necessarily.

When a new PBM is chosen there is not always a process for this change in place for you, the patient. There is no conversation with a smooth transition like in a hospital situation.?Instead, there is a black hole, and your file is in it.?No one has your file. It’s stuck in the cloud somewhere. And you are left to figure this out.?By yourself.

But until this important change happens, you will need to advocate for yourself and ask in advance what process is in place if/when this happens. Whether you are a specialty care patient or not.?And always remember ….If it doesn’t make sense to you, it probably doesn’t make sense.?Don’t stop until it makes sense.?

Lauren Kopsick has been a Parent Navigator for the last 20 years, a facilitator of pediatric/adult support groups, an advocate for many others including her own children.? She pays what she learns forward in hopes to save everyone and anyone from time-wasting, psychological and financial crippling mistakes.?For all involved. The patient, the employer and the insurance company.?Especially our underserved youth and their families.