Healthcare Data Orchestra: Why rising drug denial signals indicate better coordination is needed

They say orchestra is where everyone has different instruments, and everyone has their own score music, and no one sounds right until the conductor merges them together. Some people play too much. Others are unhappy. Strings want Allegro, while brass prefer Andante. However, when properly coordinated, something beautiful appears.

Healthcare in the United States is not much different, but here’s the headlines: Healthcare Prescriptions deny that every stakeholder, payer, provider, pharmaceutical company and patient in the story acts completely rationally based on the information, incentives, and constraints they face. Payers do not deny that medication is difficult; they are using incomplete data to make risk-based decisions while managing limited resources for millions of members. Providers are not trying to drive profits too much; they focus on individual patients’ needs without understanding the broader utilization model or cost impact.

The real story is not about rejection rates or stakeholders acting as villains. It's about a health care system that forces smart, kind professionals to make critical decisions in information silos. From 2016 to 2023, private insurers’ prescription drug denials jumped 25%, affecting nearly a quarter of patients seeking drugs, and the healthcare industry focuses on symptoms rather than potential dysfunction. When the health plan reviews treatment requests, it sees diagnostic codes and costs, rather than the physician’s clinical reasoning or the patient’s full journey. When doctors prescribe treatment, they are making decisions based on their individual clinical needs without understanding payer policies or alternative therapies may be equally effective.

We have built a health care system that rewards stakeholders to optimize their individual patient journeys rather than coordinate shared outcomes. The results are completely foreseeable: rational participants make rational decisions, thereby creating unreasonable results. The real problem is not that any single stakeholder performs poorly. It is the members of our Healthcare Orchestra that cannot communicate effectively.

This coordination challenge is more important than a single blaming game. Healthcare brings together patients, payers, providers, drug manufacturers, pharmacy welfare managers, employers, government agencies, and more, and each has its own expectations, incentives and desired outcomes. What is the benefit of one group to another group complicating the lives of another group. Policies that increase access can challenge profitability. Innovation in treatments may increase costs. The efficiency of one stakeholder introduces another benefit.

In this environment, it is not only impossible to make everyone happy, but it is also impossible. This complexity creates data fragmentation, resulting in inappropriate prescription rejection.

When payers have to evaluate coverage requests without a complete patient history, when providers lack real-world effectiveness data for new treatments, when pharmaceutical companies design clinical trials without a representative patient population, the result is exactly what we see: deciding on incomplete information can ultimately harm patients and swell costs.

Understand the challenges of command

Healthcare stakeholders must actively coordinate decisions that affect patient outcomes. Think of it as a complex orchestra:

• Payer (Copper tube section) must balance member access and financial sustainability without a complete clinical environment and make frequent coverage decisions;
• Provider (String) A comprehensive patient history is required to make the best treatment recommendations, but lacks visibility into cost impact and payer policy;
• Pharmaceutical companies (Woodwind) Develop treatments based on clinical trial data that may not reflect the limitations of the patient population and payer in the real world; and
• patient (Audience) experience music, but often fail to hear the contribution of each part to the overall performance.

The challenge is not that any part of it performs poorly, but that they often play on different scores.

The information gap behind rising denials

I have witnessed this coordination barrier firsthand while working with healthcare organizations across the ecosystem. Recently, I have observed a payer working to evaluate coverage requests for complex tumor treatments. It has basic diagnostic codes and cost information, but lacks the comprehensive patient journey data needed to understand why prescribers choose this particular therapy over an alternative.

Meanwhile, the clinical principles of prescription oncologists are detailed, but there is limited visibility into the medical policy requirements and prior authorization process for the payee. The pharmaceutical company has extensive clinical trial data on supporting treatment, but the minimum real-world evidence demonstrates the effectiveness of similar patient populations in the health program.

Both parties make reasonable decisions based on the available information. However, without coordination, shared “score”, the results are predictable. The patients with delays, denials, appeals and depression were arrested in the middle.

This pattern is repeated continuously. It takes an average of seven months for healthcare organizations to integrate and clean data before they can be leveraged for insight. During this period, patients wait, accumulated costs and opportunities for optimal care are reduced.

Balancing the view of payers and providers covering challenges

It is important to understand the legal restrictions the payer faces when making coverage. Health programs manage limited resources while ensuring proper care is provided to millions of members. They must:

• Equitically evaluate treatment in different patient populations with various clinical needs;
• Prevent improper use This adds costs to all members;
• Complex clinical guidelines for navigation Usually lack of clear realistic validity data; and
• Balanced Innovation Visit Financially sustainable, making underwriting affordable.

Likewise, when providers express frustration with previous authorization requirements or negative negligence, this is because they operate at the individual patient level. Clinicians have witnessed first-hand the urgency, complexity, and nuance of patient care. They must:

• Advocate timely access to what they believe is the most effective treatment for patients;
• Clinical decisions are made based on their expertise and direct patient interactions;
• Navigating administrative barriers that can delay care and erode patient trust; and
• Expectations for patients managing more well-known and demanding personalized care continue to rise.

Although providers often lack a broader financial or demographic level consideration that payers must consider, their focus is on providing immediate evidence-based care. When they delay using leverage management tools, it’s not about bypassing safeguards, but about ensuring that real people don’t fall into the cracks in systems designed to work at scale.

Build better coordination

The solution to healthcare stakeholder tensions is not to choose every aspect, it is building infrastructure that allows all aspects to work better together. This means enabling smarter information sharing when respecting the legitimate restrictions of each stakeholder: clinical complexity; privacy requirements; regulatory frameworks; and business reality.

This is not a forced agreement, but a meaningful coordination condition. It is about focusing on cross-stakeholder insights that provide patients with better outcomes, providing payers with smarter risk management, provider operational efficiency, and innovation in life sciences while maintaining privacy and retaining competitive boundaries. Neutral data arbitrators can power trusted platforms to enable all stakeholders to work from a common understanding (ordinary score), thus removing the collaboration required to reduce the burden of disease at scale.

Real-world success story

Some healthcare organizations have pioneered collaborative methods that can measurable outcomes. For example, working with oncology data partners can enable pharmaceutical companies to better understand real-world treatments, help them design clinical trials that reflect actual patient populations, and develop medical affairs strategies that support appropriate prescriptions.

Partnerships like this show when stakeholders prioritize patient outcomes and system efficiency over hoarding issues. The key is to build trust through transparency in data usage while ensuring that all parties benefit from enhanced insights.

The way forward

Healthcare leaders should view the current coordination challenges as evidence of stakeholder conflict, but rather an opportunity to build the collaborative capabilities required for long-term success. Now, organizations that develop strong information sharing partnerships will provide coordinated care options while maintaining operational efficiency.

An infrastructure that supports better coordination, standardized data formats, secure sharing protocols and real-time synchronization can simultaneously improve clinical decision-making, simplify administrative processes, and accelerate beneficial innovation. Those who continue to operate in isolation will have difficulty providing the coordinated care that patients deserve, and all stakeholders ultimately want to provide.

Make beautiful music together

Just like the orchestra, the health care system has nothing to do with playing solo performances, but rather about creating harmonious outcomes for a broader purpose. Current systems view healthcare data as a proprietary asset that must be protected, rather than a coordinated resource that can benefit everyone.

In fact, comprehensive insights create value across the ecosystem: better outcomes for patients; more effective operations for providers; improved risk assessment for payers; and provide pharmaceutical companies with more effective treatments.

Healthcare transformation requires recognition that the increase in rejection of drugs is not evidence of the ruthlessness of the payer or the ignorance of the provider, but rather a symptom of the coordination challenges that technology and collaboration can address. With common information and consistent incentives, we can build a system in the appropriate treatment while managing costs responsibly.

Sometimes the most beautiful music comes from the orchestra, and each part learns to support the contributions of others. Healthcare is ready for this behavior.

Photo: Pongschole1, Getty Images

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