Walking Through: Navigating Insurance & the Art of Medicine
Walking Through the Brambles
Robert Frost once wrote, “The best way out is always through.” That simple line, often invoked to describe everything from personal grief to professional frustration, feels surprisingly apt when you’re staring down a stack of open–enrollment forms (it’s October y’all!). In an ideal world, we wouldn’t have to talk about insurance at all. We’d simply prescribe the best care and patients would receive it without worry. But in the world we inhabit, coverage, formularies, and premiums shape more than our bank statements. They shape the very conversations we have about health.
Every autumn, the U.S. health system enters a season when paperwork and policy overlap with the most intimate aspects of care. People choose or renew plans for the coming year, deciding which networks to join and how much risk to assume. These choices ripple out in ways both mundane and profound. They determine whether a beloved physician remains in network, whether a brand–name medication is affordable, or whether a reassuring test can be obtained without breaking the bank. For clinicians, these seemingly bureaucratic details are more than administrative noise. They influence treatment plans, patient adherence, and the ethical calculus of resource use.
The numbers paint a stark picture. According to research on patient–provider cost conversations (Richards et al., 2022), 92 percent of patients want to know their expected out‑of‑pocket costs before treatment, 81 percent say they want to discuss those costs with their doctor, and 76 percent feel comfortable having those conversations. Yet only around 14–15 percent actually have cost discussions before receiving tests or treatments (Richards et al., 2022). This gap—between what people want and what happens—has real consequences. In 2023, more than one quarter of U.S. adults (28 percent) delayed or went without healthcare because of cost, and nearly half (45 percent) worry about paying medical bills if they get sick or have an accident (Rakshit et al., 2025). For uninsured adults, the situation is even more precarious; they are more than twice as likely as insured adults to delay or skip care because of cost (Rakshit et al., 2025). When we avoid talking about coverage, we aren’t sparing patients a tedious conversation. We are leaving them to navigate a maze blindfolded.
Clinicians feel the tension too. In a 2025 poll, 63 percent of physicians said they consider the cost of care “all” or “most” of the time when deciding on treatment options (Sermo Team, 2025). They see the financial strain on their patients: 64 percent reported that their patients occasionally or often refuse recommended treatment because they cannot afford it (Sermo Team, 2025). Yet only 31 percent believe their patients feel very comfortable discussing financial concerns (Sermo Team, 2025). These statistics are not just numbers; they are indicators of a communication gap that influences clinical outcomes. Every time a patient hesitates to mention that the brand‑name drug is out of reach, or a provider refrains from asking whether a test is financially burdensome, an opportunity is lost to align care with reality and values.
When Frost wrote about “going through” as the best way out, he might as well have been talking to all of us trying to practice medicine within this thicket of coverage and cost. Rather than pretending that insurance doesn’t exist—or that it belongs solely in the domain of human resources—what if we embraced it as another parameter in our art? Not because premiums and formularies are inherently noble, but because acknowledging them forces us to think more deeply about what matters. It invites us to ask: What will this test tell us? Will it change what we do next? Is reassurance valuable enough to justify the cost? How do we honour a patient’s preferences when financial constraints loom large?
This reframing matters because medicine has always existed at the intersection of science and human story. We study physiology and pharmacology; we also sit with people’s hopes and fears. Coverage is part of that story. It shapes whether a patient can afford to follow through on a plan, whether they must choose between blood pressure medication and groceries, whether they walk into a clinic trusting that transparency is possible. By treating insurance talk as just another bureaucratic burden, we miss an opportunity to integrate care with the lived realities of those we serve.
Asking Better Questions in an Imperfect System
If the first step is acknowledging that coverage matters, the second is learning to make these conversations meaningful. Data alone can tell us that patients want to know costs and that providers consider them, but numbers don’t teach us how to talk. The art of medicine lives in the how: in the questions we ask, the pauses we allow, the way we balance evidence with individuality. Insurance, paradoxically, can sharpen that art. By forcing us to account for costs and formularies, it pushes us to be more explicit about what each test or treatment offers—and what it doesn’t.
Take the common scenario of ordering a diagnostic test that is unlikely to change management. In a world without costs, perhaps we would order freely, if evidence of benefit were questionable but the risk was low. In our world, the calculus includes not only potential harm and benefit but also financial burden. Does the patient want the reassurance of a “normal” lab value? Will that reassurance reduce anxiety and prevent further visits? Or will it simply satisfy curiosity without altering treatment? These are questions clinicians might have asked themselves privately; when insurance is part of the equation, we have to ask them aloud. Doing so does not cheapen the encounter; it enriches it. It invites the patient into the decision‐making process, acknowledges their autonomy, and respects their resources.
This isn’t to say every conversation should be about cost. In fact, one of the nuances highlighted by the data is that people have different needs. Some patients crave every datapoint; they want to understand the details, weigh probabilities, and decide accordingly. Others want a straightforward plan without the burden of sifting through numbers. Many fall somewhere in between, trusting their clinician’s judgment but appreciating an honest discussion about affordability when it becomes relevant. As clinicians, our task is not to impose a particular decision but to match our guidance to the person in front of us. That means being comfortable with what my students once dubbed a “Shurson‑ism”: answering questions with “maybe.” Maybe we order the test; maybe we wait. Maybe a generic medication is just as effective; maybe there’s a compelling reason to use the brand. “Maybe” is not indecision; it is openness to context.
Ethically, these conversations touch on more than economics. They bring to the surface principles that are too often implicit: respect for autonomy, justice in the allocation of resources, beneficence balanced against nonmaleficence. When we discuss whether to pursue a costly therapy, we are also exploring the patient’s values—what outcomes matter most, what trade‑offs they are willing to accept. When we recommend a generic drug or a lower‑cost imaging center, we are practising justice by acknowledging that high quality care does not always require the most expensive option. And when we counsel a patient not to pursue a test that will not change their management, we are honouring the principle of nonmaleficence by avoiding unnecessary harm—financial harm included.
Still, these discussions can be fraught. Providers worry about appearing insensitive or paternalistic. Patients worry about seeming unable to afford care or fear that raising cost concerns might compromise the quality of what they receive. The Sermo poll underscores this discomfort: despite clinicians’ awareness of cost pressures, only about a third feel their patients are comfortable discussing finances (Sermo Team, 2025). This gap calls for deliberate skill building. The same way we learn to take a history, deliver bad news, or perform a procedure, we can learn to integrate cost awareness into our clinical reasoning and communication. We can normalise asking, “Do you have concerns about the cost of this medication?” and reassure patients that such questions are welcome.
Importantly, not every visit is the right time for a deep dive into benefits and deductibles. A patient with chest pain needs evaluation first; financial counselling can wait. But by raising the topic proactively at appropriate moments—annual exams, care planning visits, medication reviews—we open the door. In doing so, we also relieve some of the anxiety that arises when costs surface uninvited, as surprise bills or denials. The Frostian wisdom applies here too: the best way to move through the thicket of cost is to face it together, bit by bit, rather than letting it ambush us later.
Navigating Together: The Role of a Health Advisor
As much as we champion cost conversations, we must acknowledge the limits of the clinical encounter. Appointments are brief; clinicians are stretched thin; administrative tasks are multiplying. Asking a physician, nurse practitioner, or physician assistant to master every insurance nuance is unrealistic. And asking patients to navigate formularies and deductibles alone is unfair. This is where a health advisor model—like Storyline Health Navigation—finds its purpose.
A health advisor sits at the intersection of benefit expertise and clinical insight. For patients, this means having an ally who can clarify when to raise questions about coverage, compare plan options, and help prepare for open enrollment. Instead of calling an insurer with a list of medications and hoping for clarity, a patient can work with a Storyline advisor to map out what each plan covers, what the cash prices might be for important labs, and how to budget for potential health needs. It’s not about selling insurance; it’s about translating it so that patients can make informed choices that align with their values and health goals.
For clinicians and practices (especially smaller or independent ones) a health advisor relieves a significant burden. Many practices lack the staff time to research formulary changes, assist with prior authorizations, or counsel on financial assistance programs. When 64% of physicians say patients sometimes refuse treatment because they can’t afford it and only a third of patients feel comfortable discussing cost (Sermo Team, 2025), there is a clear need for a bridge. A health advisor can step into that gap, ensuring that cost discussions happen without derailing the flow of a visit. They can act as a liaison between the patient’s insurance realities and the clinician’s treatment plan, suggesting alternatives when coverage is an obstacle or confirming when a test is indeed necessary despite a higher co‑pay.
Moreover, a health advisor can help shift the narrative from “How much will this cost?” to “How can we make this work?” That shift is powerful. It reframes insurance not as an adversary but as a framework within which we exercise agency. It invites both patient and provider to think creatively: exploring generic medications, utilising discount programs, scheduling elective procedures when deductibles reset, or, in some cases, postponing tests until coverage is clarified. This approach aligns with the Frostian ethos of moving through difficulty rather than avoiding it. It acknowledges that while the insurance landscape is imperfect, we can navigate it thoughtfully and ethically.
In many ways, the emergence of health advisors reflects a broader movement in healthcare toward holistic support. We recognise that health is influenced not just by biological factors but by social determinants, financial stability, and administrative complexities. A patient with controlled asthma may still end up in the emergency department if their inhaler becomes unaffordable. A patient newly diagnosed with diabetes may forgo home glucose monitoring because test strips aren’t covered. Addressing these issues requires more than clinical knowledge; it requires an infrastructure that respects the interplay of policy and personal experience.
As we move into the heart of open enrollment season, consider how Frost’s line can guide us. Instead of dreading the forms and formulary changes, we can see them as a moment to align care with individual priorities. We can prepare by gathering medication lists, identifying preferred providers, and noting the tests or treatments likely to be needed in the coming year. For clinicians, it’s an opportunity to check in: Are there low‑cost alternatives we should consider? Do we need to revisit our use of brand‑name medications? Are there labs or imaging studies we typically order that rarely change management? These questions are not an indictment of our practice; they are a recognition that excellence in medicine includes stewardship of resources.
Ultimately, weaving insurance into the art of medicine doesn’t diminish our craft; it enriches it. The best way out of the frustration and fragmentation is indeed through: through honest conversations, through collaborative decision making, through support systems like health advisors that make complexity manageable. When we walk through together—patient and provider, clinician and health advisor—we transform coverage from a barrier into another tool for aligning care with values. Frost reminds us that by embracing the path we have, thorns and all, we may find ourselves in a clearing where care is not only effective but also sustainable and just.
References
Richards, et al. Patient perspectives on provider responses to healthcare costs and how informatics interventions can help support cost-sensitive care decisions. Journal of the American Medical Informatics Association, 29(6), 1029\u20131039. https://doi.org/10.1093/jamia/ocac010
Rakshit, et al. (2025, April 7). How does cost affect access to healthcare? Peterson\u2013KFF Health System Tracker. https://www.healthsystemtracker.org/chart-collection/cost-affect-access-care/
Sermo Team. (2025, June 12). How far do physicians consider the cost of healthcare? Sermo. https://www.sermo.com/resources/considering-the-cost-of-healthcare/