Barriers Aren’t Bugs. They’re the Business Model.

Traditional health plans require you clear 3 gates before you are allowed to get better.

• Cost-Sharing. This is the toll you pay just to get into the game.
• Self-Navigation. This is the part where you get to find your own way without a map.
• Prior Auth. This is the locked door that only opens when someone you can’t see decides you’ve earned it.

Many people will tell you these exist to control cost. They don’t control cost. They control access, and they do it by making care expensive, confusing or slow enough that you give up before you get to where you need to be.

Those are not side effects. That’s the design.

Copays Don’t Create Smart Consumers. They Create Ghosts.

The industry loves the phrase “skin in the game.” What that means is: charge people enough that some of them quietly disappear.

Here’s what that actually looks like today:

• Across 79 studies spanning a decade, one pattern holds no matter the disease: the more you charge, the worse people are at sticking with the treatment. Not a little worse. Dose-dependent worse, meaning the more it costs, the more people quietly stop.
• Even with the ACA’s preventive services mandate in place, Members with high-deductible plans still skip recommended screenings and follow-up care at higher rates than everyone else. The deductible doesn’t have to touch the exact test. Just existing in the background is enough to make someone decide it isn’t worth the hassle.
• U.S. Members juggling three or more access barriers, cost being the biggest one, get screened for lung cancer at rates up to 32% lower. Not because they don’t care. Because the paperwork and the price tag together feel like a symptom on their own.

Nobody wakes up excited to skip care. They wake up and do math, and the math says ““Not Today.”

“Manage Your Own Referral” Is Not Empowerment. It’s Abandonment With a Portal Login.

Here’s how that goes:

• Referrals fall apart most often because nobody explained why they mattered, and then the scheduling system makes booking one feel like helping your elderly parent reset the password on their AppleTV.
• Less than half of primary care doctors even find out what happened after they sent a Member somewhere. The Member becomes the only person tracking their own care, which is a wild job to hand someone who is, again, sick.
• About three in four insured U.S. adults do some kind of insurance homework every year. Roughly a quarter of them delay or skip care because the homework wins.

This isn’t a system that trusts Members to be adults. It’s a system betting that most of them will give up before the second phone tree.

Prior Authorization Has a Body Count, and Doctors Will Tell You That to Your Face

Of the three tools, this one doesn’t even bother with plausible deniability.

A 2025 review across oncology, cardiology, behavioral health, and pediatrics found prior auth tied to delayed care, disease getting worse, avoidable hospital stays, and worse survival. Not “inconvenience.” Survival.

And when you ask actual physicians, not think tanks, the numbers get uncomfortable: the overwhelming majority report prior auth causing delays, most report it hurting outcomes, and roughly a quarter to a third have seen it lead to a serious adverse event. Including death.

The people getting hit hardest by these delays are the Members with the most serious conditions. So the tool built to “manage risk” is landing squarely on the people who can least afford to wait.

Here’s the Part That Should Really Ruin Everyone’s Day

None of it saves money.

Crank up cost-sharing and spending doesn’t vanish – it shifts. Not only does it shift cost to members in need it moves from a cheap outpatient visit to an expensive inpatient stay. Plans that cut or eliminated copays didn’t see total costs go up. So the entire premise, that making Members pay more controls spend, doesn’t even hold up on its own terms.

These aren’t precision tools. They’re a sledgehammer sold to you as a scalpel, and Members are the ones getting pounded on.

What You Should Do Instead

Here’s the logic. If a Member needs a screening, an MRI, or a scoped procedure that catches a real problem early, the last thing on earth you want is a copay or a deductible standing between them and it. So take it off the table.

Why. Because a $200 deductible that talks someone out of an MRI doesn’t save $200. It just delays the day that same problem shows up as a $30,000 emergency instead of a $3,000 outpatient visit. Build a plan design that stops charging Members for doing the responsible thing, because the “responsible thing” is the cheapest thing every single time it happens early instead of late.

It also means steering Members to care that’s already priced honestly. Gallbladder surgery on a direct contract runs about $5,700. Show up to an ER for the same thing and that bill can land closer to $17,000, for the same organ, removed the same way, by the same kind of surgeon.

For 20 years or so (thanks to Mark Fendrick) we have known that it makes a lot of sense to eliminate cost-sharing for Members managing certain conditions. Why make Members pay to find out something’s wrong, and then make them pay extra for getting it fixed the smart way instead of the expensive way.

It’s also why you shouldn’t leave members to self-navigate the system. Ask the concierge at a Four Seasons where the pool is, and they don’t point down the hall and go back to their phone. They walk you there. That’s the whole model. Escort Members through the system instead of letting someone else point at a map and walk off.

For anyone keeping score at home:

• Cost-sharing doesn’t build smarter Members. It builds Members who vanish before the appointment.
• “Manage your own referral” is not a feature. It’s a chore outsourced to a sick person.
• Prior authorization has the clearest evidence of real harm, and it lands hardest on the Members who needed help the most.
• None of these three tools reliably lowers total cost. They just move the risk somewhere quieter.

Your Homework (Sorry):

Here’s a free idea, and you won’t have to do really any of the work.

Pull up your Summary Plan Description. If you want the version people actually read, grab your SBC too. Then take the 17 studies at the bottom of this post and dump the whole pile, SPD, SBC, and studies, into a Claude Project.

Then ask it one question: where does my plan design ignore the evidence?

Not “is my plan good.” Not “am I competitive.” Ask it to hold your actual plan document up against actual peer-reviewed research and tell you, line by line, where your cost-sharing, your referral process, and your prior auth rules are doing the opposite of what the evidence says works.

You will not like everything it tells you. That’s the point.

1. Cost-Sharing and Adherence, Clinical Outcomes, Health Care Utilization, and Costs: A Systematic Literature Review. Fusco N, Sils B, Graff JS, Kistler K, Ruiz K. Journal of Managed Care & Specialty Pharmacy. 2023;29(1):4-16. doi:10.18553/jmcp.2022.21270.
2. Cost-Sharing and the Utilization of Clinical Preventive Services. Solanki G, Schauffler HH. American Journal of Preventive Medicine. 1999;17(2):127-33. doi:10.1016/s0749-3797(99)00057-4.
3. Increased Cost Sharing and Changes in Noncompliance With Specialty Referrals in the Netherlands. van Esch TE, Brabers AE, van Dijk CE, et al. Health Policy (Amsterdam, Netherlands). 2017;121(2):180-188. doi:10.1016/j.healthpol.2016.12.001.
4. The Effect of Cost-Sharing Design Characteristics on Use of Health Care Recommended by the Treating Physician; A Discrete Choice Experiment. Salampessy BH, Alblas MM, Portrait FRM, Koolman X, van der Hijden EJE. BMC Health Services Research. 2018;18(1):797. doi:10.1186/s12913-018-3598-4.
5. Barriers to Health Care and Cancer Screening. Gurayah AA, An A, Kuchakulla M, et al. JAMA Network Open. 2026;9(4):e267024. doi:10.1001/jamanetworkopen.2026.7024.
6. Social Risks and Nonadherence to Recommended Cancer Screening Among US Adults. Sedani AE, Gomez SL, Lawrence WR, et al. JAMA Network Open. 2025;8(1):e2449556. doi:10.1001/jamanetworkopen.2024.49556.
7. Patient Perspectives on Delayed Specialty Follow-Up After a Primary Care Visit. Fernández L, Ricci D, Pollack A, et al. Journal of the American Board of Family Medicine : JABFM. 2025;38(1):139-153. doi:10.3122/jabfm.2024.240063R3.
8. Patient Experiences With Coordination of Care: The Benefit of Continuity and Primary Care Physician as Referral Source. O’Malley AS, Cunningham PJ. Journal of General Internal Medicine. 2009;24(2):170-7. doi:10.1007/s11606-008-0885-5.
9. Care Coordination for the Chronically Ill: Understanding the Patient’s Perspective. Maeng DD, Martsolf GR, Scanlon DP, Christianson JB. Health Services Research. 2012;47(5):1960-79. doi:10.1111/j.1475-6773.2012.01405.x.
10. Patient administrative burden in the US health care system. Kyle MA, Frakt AB. Health Services Research. 2021;56(5):755-765. doi:10.1111/1475-6773.13861.
11. Health care administrative burdens: Centering patient experiences. Herd P, Moynihan D. Health Services Research. 2021;56(5):751-754. doi:10.1111/1475-6773.13858.
12. Administrative Burden Associated With Cost-Related Delays in Care in U.S. Cancer Patients. Doherty M, Thom B, Gardner DS. Cancer Epidemiology, Biomarkers & Prevention : A Publication of the American Association for Cancer Research, Cosponsored by the American Society of Preventive Oncology. 2023;32(11):1583-1590. doi:10.1158/1055-9965.EPI-23-0119.
13. Adverse Effects of Health Plan Prior Authorization on Clinical Effectiveness and Patient Outcomes: A Systematic Review. Murphy J, Beauchamp N, Sun KJ, et al. The American Journal of Medicine. 2025;:S0002-9343(25)00553-4. doi:10.1016/j.amjmed.2025.08.018.
14. Delays Related to Prior Authorization in Inflammatory Bowel Disease. Constant BD, de Zoeten EF, Stahl MG, et al. Pediatrics. 2022;149(3):e2021052501. doi:10.1542/peds.2021-052501.
15. Barriers and Consequences of Prior Authorization for Neurologic Medications. Gotlieb E, Joseph B, Blank L, Jetté N. JAMA Neurology. 2025;:2842313. doi:10.1001/jamaneurol.2025.4560.
16. Prior Authorization and Associated Delays and Denials of Branded Medication Dispensation. Yang Wang, PhD, Joseph F. Levy, PhD, T. Joseph Mattingly, PharmD, MBA, PhD, et al. JAMA Health Forum. 2026. doi:10.1001/jamahealthforum.2026.0760.
17. Socioeconomic, Geospatial, and Geopolitical Disparities in Access to Health Care in the US 2011-2015. Towne SD. International Journal of Environmental Research and Public Health. 2017;14(6):E573. doi:10.3390/ijerph14060573.