Founder’s Corner: Navigating Care When the System Doesn’t Make It Easy
There’s a side of this industry that doesn’t show up in plan documents, renewal spreadsheets, or benefit summaries, instead it shows up when someone needs care.
A medication I’ve taken for years was suddenly denied.
What followed were numerous phone calls, time on hold, and conversations that didn’t quite connect. The insurance companies customer service couldn’t provide a clear answer. The specialty pharmacy had a different perspective. The provider’s office was trying to help but didn’t have full visibility into what had changed.
At one point, it felt like everyone was working with a different set of information.
With persistence and access to the right resources, I eventually pieced it together. And it was relatively simple; the formulary had changed.
The medication itself hadn’t. My need hadn’t. But the way it was categorized and covered had shifted and that change hadn’t clearly translated across the different parts of the system.
This experience made me stop and think:
What happens when someone doesn’t have the time to sit on hold for hours?
What happens when they don’t know which questions to ask, or who to push, or where to go next?
What happens when the process becomes so frustrating that they simply give up?
This is the part of healthcare that is rarely talked about. Not the coverage itself but the navigation of it. Who helps with:
The coordination between providers, pharmacies, and carriers.
The gaps in communication.
The time it takes to advocate for something that should feel straightforward and is often necessary.
And while these systems are built with structure and intention, the experience for the individual can still feel fragmented.
It’s a reminder that access to care isn’t just about having coverage, it’s about being able to use it.
Not everyone has the same level of access to information or support. And that reality matters because it raises important questions not just for individuals, but for employers, advisors, and those of us who work within this space:
How do we make this easier to navigate?
How do we better support employees when they’re in moments that require care?
How do we close the gaps between the systems that are meant to work together?
It’s also a reminder of how important it is to have someone in your corner, someone who understands the system, can help connect the dots, and is willing to stay with you until there’s clarity.
At Tandem, that level of advocacy and follow-through isn’t an added service, it’s a core responsibility we take seriously.
We recognize that at the end of the day, the value of a health plan isn’t just measured by cost or design, it’s measured by what happens when someone needs it.
