Here’s a question that should sound ridiculous: If a benefit design requires an A1c above a specific cutoff to access a therapy that prevents long-term organ damage, what happens to the patient who is just below the line?
Not below the line in a meaningful biological way. Below the line in a policy way.
6.8 instead of 7.0. or 6.4 instead of 6.5
A rounding error with a different moral outcome.
This is the fulcrum where modern coverage logic turns ugly. It isn’t because someone is twirling a mustache; it’s because the system is not built to accommodate a patient-centered rules gradient. If the only way to get help is to look slightly worse on paper, the system quietly teaches people to become worse—or to make the paper lie.
That is the phenomenon I want to name: Administrative Pathogenesis. It is the condition where the rules governing access create incentives for pathology to progress.
When a Measure Becomes a Password
A1c is a useful clinical signal. But in coverage design, measures are rarely treated as signals; they are treated as passwords. You either have the number, or you don’t. You either enter, or you don’t.
This is Goodhart’s Law in a white coat: When a measure becomes a target, it stops being a measure. The moment “A1c ≥ X” becomes the key that unlocks care, the system stops asking what the number was meant to represent: risk, trajectory, or need. It becomes a single digit deciding whether you get to enhance your future with pharmacologic therapy. We shouldn’t be surprised when people start treating that digit like a hurdle instead of a truth.
Here’s the table that demonstrates this clearly:
Metric | Patient A | Patient B |
Baseline A1c | 7.0% | 6.8% |
Coverage decision | Approved | Denied |
Intervention | GLP-1 + lifestyle | Lifestyle only |
1-year A1c, post-determination | 5.0 | 6.9 |
Risk trajectory | Dramatically reduced | Slightly worse |
System verdict | Success | Still ineligible |
The Perverse Incentive Cliff
Coverage cliffs present as governance. Biology is continuous. It slopes and drifts in response to stress, sleep, wellness inputs and measurement timing. Coverage, however, is a step function: Approved or Denied.
When reality is a slope and policy is a cliff, the friction doesn’t disappear. It moves downstream. It turns into administrative burnout, delayed starts, and—let’s say it plainly—data that isn’t aligned with reality.
“Technically Correct” Can Be Clinically Malicious
In the old world, pharmacists were trained to verify the drug: the product, the dose, the interaction. In the new world, that part is increasingly automatable. The human burden has shifted to a more convoluted question: Is the logic governing access valid?
You can be technically correct and clinically malicious at the same time. I’ve personally seen the system deny a high-risk patient requesting access to Mounjaro because they are at 6.8% A1c instead of 7.0% A1c. Without any decision-making power to override, this is where moral injury is born: when the job requires you to participate in harm while calling it “policy.”
The Temptation Isn’t the Point—the System Is
Let’s address the taboo: When a policy requires the appearance of being sicker to access the tool that prevents sickness, it creates a rational incentive to “help the metric along.”
Could this look like patients eating differently before a lab draw—not to get healthier, but to get covered? Sometimes it looks like documentation emphasis toward what “counts” instead of what matters to the clinician-patient dynamic.
“Fraud” as a Downstream Symptom
Compliance culture treats fraud as an individual moral failure. But in benefit design, much of what we call “fraud” is a downstream symptom of upstream incentives.
If the cost of honesty is losing access, honesty becomes expensive.
If the cost of precision is more paperwork, precision becomes rarer.
This is why watchdoggery matters: not to “expose evil,” but to make incentive gradients visible so we stop moralizing outcomes that are structurally produced.
The New Job of the Pharmacist
Pharmacists don’t just verify molecules anymore—they verify meaning. More and more, the work is noticing when a threshold becomes a password, when a decimal point decides who gets help and who gets told to wait.
The watchdog names the cliff. Documents the indirection. Keeps the analysis anchored to receipts.
What you do with that information is yours.