Open enrollment can be a ‘House of Horrors’: 4 monsters for patients to beware

October is the scariest time of year. Young goblins walk the streets demanding treats, local haunted houses are packed full of fright-chasing teens, and the airwaves are filled with gore-splattered slasher flicks. 

For those weighing health plans as a part of open enrollment, October brings its own horrors. The shadowy number crunchers working in the bowels of insurance companies have brought to life all manner of lumbering creations, each diabolically designed to hamper access. 

Here are the four most frightening monsters set to terrorize beneficiaries: 

• Excessive Cost-Sharing. Study after study has shown that forcing patients to shoulder a portion of the costs of their chronic disease medicine does little to encourage responsible use, but instead—like a vampire—sucks away patient savings and compromises adherence.  
• Fail First. This isn’t the monster mash: many insurance plans demand that patients try medicines that they and their physicians know won’t work just to get access to the medicines that are truly needed. These policies—also known as step therapy—are rooted in insurance company magic, not evidence. One analysis found that step therapy rules for psoriasis were stricter than clinical guidelines 99% of the time.
  
• Prior Authorization. For many medicines, insurance companies require pre-approval before a treatment can be reimbursed. But that process—like killing the villain in a scary movie—generally requires multiple attempts. Often, just when the process seems complete, the insurance company will again lurch to life with another demand. This latter-day zombie uprising is a scourge upon physicians, with 14 hours a week per doctor spent battling insurance companies.
  
• Formulary Changes. There’s scarcely a culture on earth that doesn’t have a myth about a terrifying shapeshifter that can alter its appearance to sow discord and chaos. Turns out, insurance companies have their own chameleon-like tendencies, swapping drugs in and out of formularies each year (and sometimes even during the year). That makes it critical for patients and employers to double-check to make sure that their Dr. Jekyll plan doesn’t become a Mr. Hyde one when the calendar flips.

Complicating all of this is a lack of transparency. Much like midnight fog over a cemetery, the reality of health coverage is often hazy. Sunlight not only kills vampires, but it does a pretty good job of banishing the shadows around health benefit design, too.