Congress: Put Professionals Back in Charge of Treatment Decisions

When an estimated 113 million Americans cast their votes in the 2018 midterms, health care was on the ballot in every state. According to exit polls, 41 percent of voters said the need for health care is the most important issue facing the country, and more than seven in 10 said the nation’s health care system needs major changes.

Now, the question is how Congress and state legislatures will make these changes. Voters called on lawmakers to keep health insurance affordable and expand Medicaid in certain states. They also pressed congressional leaders to preserve the pre-existing condition protections required by the Affordable Care Act, which is absolutely critical for the six in 10 adults in the U.S. who have a chronic disease like heart disease, diabetes and cancer.  

Yet, these safeguards will not go far enough to ensure that Americans receive optimal medical care. There are other serious issues confronting our health care system that go to the core of quality health care; namely, our nation’s health care professionals are increasingly losing their autonomy due to the cost-savings strategies employed by health insurers.

According to a recent survey of 600 physicians practicing family medicine, internal medicine, pediatrics, and obstetrics/gynecology commissioned by the Alliance for the Adoption of Innovations in Medicine (Aimed Alliance), 89 percent of primary care physicians said they no longer have adequate influence in making health care decisions for their patients. Instead, those making the decisions tend to be the staff of health insurers whom 92 percent of physicians described as not competent to make medical decisions about treatment regimens.

Doctors surveyed also said that decisions made by unqualified health insurers’ personnel interfere with their ability to prescribe needed treatments for their patients and have a negative effect on patient care. One practice denounced by 90 percent of primary care physicians surveyed is step therapy, which forces patients to try and “fail” on one or more less-expensive treatments first before the health insurer will cover what the health care provider prescribed. Especially when patients are fighting a life-threatening disease, the delay can lead to disease progression and ultimately prove fatal.

Similarly, 91 percent of doctors surveyed point to two common health insurance practices — nonmedical switching and prior authorization — as particularly harmful for patients. With nonmedical switching, insurers force patients who are doing well on a specific drug to take a different, usually less-effective medicine to boost profits, by either refusing to cover the drug any longer or increasing the out-of-pocket cost of the drug.

Insurers can also require the patient or health care provider to gain approval, or prior authorization, before the treatment is covered. The survey found that 87 percent of physicians worry that their patients’ conditions could worsen due to the lag time caused by the prior authorization process, and 83 percent fear that their patients may experience prolonged pain or disability.

Beyond the harm to patients, the Aimed Alliance research is also a wake-up call to policymakers concerned about the escalating shortage of primary care doctors, which could reach between 14,800 and 49,300 practitioners by 2030. As more health insurers override doctors’ decisions and require costly administrative time for practices to handle paperwork, the survey reveals that almost half of primary care physicians (48 percent) are considering leaving the field of medicine, and 67 percent would not recommend a career in medicine to aspiring medical professionals. Additionally, 65 percent say they are facing greater legal risks due to health insurers’ restrictive practices.

What these new research findings make clear is that treatment decisions should be left to health care providers based on their training, knowledge of the patient’s unique needs, and professional judgement — and not to insurers. Thus, as policymakers work to preserve pre-existing conditions protections and make health insurance more affordable, Congress and state lawmakers must identify solutions that ensure Americans have timely access to the most effective treatments, tests and procedures. This will require restoring a climate where health insurers respect professionals’ treatment decisions and where providers are able to match treatment options with each patient’s individual needs.


Dr. Shannon Ginnan is a practicing physician and the director of medical affairs at the Alliance for the Adoption of Innovations in Medicine (Aimed Alliance).

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