Smashing Siloed Models and Mixed Incentives to Enable Frictionless Access

What you’ll learn

The Challenge

Picture this all too common patient experience: After months of symptoms and doctor visits, they finally receive a much-needed prescription—only to discover their insurance does not cover it. This begins a painstaking process of appeals and paperwork, where everyone loses: the patient faces delays, the doctor's recommendations are questioned, and the manufacturer, distributor, and pharmacy lose a revenue opportunity.

This narrative doesn’t just highlight individual struggles, it underscores a $150 billion industry challenge marked by 20–30% of prescriptions that never reach the patients who need them. Built with the best intentions, the existing methods of connecting patients with prescriptions have become obsolete.

Why is this happening?

The challenge extends beyond the siloed structure of our healthcare system where pharmaceutical companies, insurance providers, pharmacy benefit managers, healthcare providers, and pharmacies each follow their own protocols with minimal interaction. Decisions on a broad scale enforce one-size-fits-all rules, prioritizing cost-efficiency at the expense of patient care. This approach leads to step-through and fail-first practices or needing an X-ray before an MRI is approved by insurance, despite a doctor’s expert judgment on a patient’s specific needs.

But it doesn’t have to be this way.

Instead, imagine a healthcare journey streamlined by the innovative use of AI, where the friction points that typically ensnare patients in a web of coverage and reimbursement disputes, calls to the HCP and pharmacy, and endless paperwork that are resolved before they even arise, making these challenges invisible to the patient.

Case Study: A New Dawn for Healthcare Connectivity

In collaboration with a leading pharmaceutical brand, Klick Health embarked on an ambitious project to turn this vision into reality. Recognizing the crucial role of executive leadership in such transformative endeavors, we initiated a comprehensive overhaul of the patient access journey. Here’s what our approach looked like in action:

Comprehensive Data Synthesis: We began by breaking down the silos that traditionally segmented the healthcare industry. By amalgamating medical data, market access information, and commercial insights, we could paint a holistic picture of the patient journey—from prescription to treatment initiation and appropriate adherence.

Predictive Analytics and AI: Using AI’s predictive power enabled us to foresee and navigate potential patient access barriers. This proactive approach turned existing patient support services—like financial aid and educational resources—into preemptive solutions. The experience for patients and healthcare providers improved and mitigated prescription abandonment, safeguarding brand revenue.

Unified Healthcare Perspective: Our strategy was rooted in a deep understanding of the entire healthcare ecosystem. We went beyond the point of prescription, considering the myriad of steps required for a doctor to prescribe, an insurer to approve, and a pharmacy to dispense medication. This comprehensive view enabled us to identify and address system gaps effectively.

Proactive Problem Solving: Armed with this insight, we could act before patients stumbled upon roadblocks. If a particular insurance plan didn’t cover medication, we facilitated the necessary steps for an appeal or alternative solution—often before the patient was even aware there might be an issue.

To further refine our approach, we explored the intricacies of various employer-based plans within each payer, identifying specific coverage rules and formularies. This granular focus allowed us to preemptively smooth out potential friction points and ensure healthcare professionals could confidently prescribe, knowing their patients would receive the necessary treatments without the delays caused by the current coverage and reimbursement process. This approach showcases the power of marrying innovative technology with strategic leadership to revolutionize patient care.

Leadership: Pioneering the Future of Patient Care

The good news is that this approach can be accomplished whether you are at an executive above-brand level or a leader within brands. Critical to the success of this initiative was the forward-thinking team that was prepared to redefine the norm. The impact of AI on healthcare goes beyond technology; it requires leaders who are committed to breaking down traditional silos and analyzing the interdependencies and impacts of functionally based solutions. By reevaluating our ways of working and incentives, we’ve encouraged collaboration across previously isolated departments, pinpointing significant opportunities for improvement. This shift in strategy ensures patients get the care they need swiftly and seamlessly.

We are now equipped to transform patient care through visionary leadership and AI. It's a four-way win for everyone involved. Past limitations and concessions to what was possible are no longer true. Personalized access and affordability decisions are scalable. Pharma companies can guarantee access for appropriate patients, increasing revenue. HCPs can ensure that the right drug for their patients is accessible and affordable, without the cost and headaches of today's administrative burden. Together, we can forge a path toward actionable, scalable strategies. Please contact us to learn more about our vision for a future where healthcare is not only accessible but also economically sustainable for everyone.