The Fallacies Around Provider-Patient Relationships and Prior Authorizations

Hey MTSBWY Subscribers,

Droids in Star Wars offer comical relief, as we see a select few exemplify quite the personalities. Whether it’s R2-D2 zapping a foe, C-3PO being oblivious to any situation despite his seemingly endless intelligence or Chopper (C1-10P) being frankly the most ornery, teenage acting piece of machinery to exist in the Star Wars galaxy (still my favorite, however).

While these three are not the only droids to display a sense of personality, their mannerisms seem to be a shock to most characters; R2 definitely doesn’t act like most astromechs. Their behavior is surprising because there is a presumed manner in which droids function or perform their jobs. Of course, we know what to expect from these droids as they sidekick for our favorite Jedi and rebels to the Galactic Empire, but others don’t.

We do this in healthcare one way or another, by having preconceived understandings of how healthcare operates. These fallacies don’t exist on just one side of healthcare, they exist in the patient care realm, with the health plan and even within PBM functions.

Today, we’re addressing some common misconceptions in healthcare—specifically, the belief that the provider-patient relationship should be exclusively between those two parties and the role of prior authorizations in guiding clinical decisions.

It’s important to remember that healthcare is a system, not just a singular interaction between patient and provider. The system is complex and includes insurers, administrators, and even processes like prior authorizations, all of which influence care delivery. But are these mechanisms actually improving healthcare? Or are they unintentionally complicating it?

Let’s dive in.

The Fallacy: Care Should Exist Exclusively Between Provider and Patient

One common fallacy I hear regularly is the idea that care should be “just between the provider and patient.” In this view, insurers and health plans should have no place in healthcare decisions. While I completely understand the intent behind this perspective—emphasizing the patient-provider relationship as the heart of care—it overlooks a few key realities.

Providers, no matter how skilled, are human. They can make mistakes, miss certain nuances, or fail to consider all potential options for a given patient. This isn’t to undermine the critical role providers play in our healthcare system; rather, it’s to recognize that the healthcare system itself needs to be better aligned to support both providers and patients.

The Impact of the Fee-for-Service Model

In the current fee-for-service system, providers are often incentivized to see as many patients as possible in the shortest amount of time. This model doesn’t encourage them to spend more time researching treatments or engaging deeply with patients about their specific needs. Instead, providers are often under pressure to make quick decisions that may not always result in the best long-term outcomes or utilize similarly effective, yet lower cost, medications.

From a medication perspective, this can mean prescribing treatments that are easy to administer and likely to have broad success across patient populations. But this approach often overlooks the subtleties of individual patient needs and the impact on healthcare spending.

This brings us to the next critical issue: how plans and vendors interact with providers and patients through mechanisms like prior authorizations.

Prior Authorizations and Step Therapy: A Double-Edged Sword

Prior authorizations and step therapy are meant to ensure that prescribed medications are clinically appropriate and cost-effective. In theory, they are a system of checks and balances, ensuring that only the most necessary treatments are approved.

But in practice, these systems are far from perfect.

1. Prior Authorization is essentially a gatekeeping mechanism. Before a provider can prescribe a certain medication, they must get approval from the patient’s insurer. This process often delays care, frustrates providers and patients alike, and in many cases, leads to patients abandoning the treatment plan altogether. This system acts as a checklist of patient characteristics which are compared to those enrolled in the drug’s clinical trials. This approach ensures the patient will likely have similar outcomes to those studies, but is far from a “clinical” approach.
2. Step Therapy, on the other hand, requires patients to try and fail with less expensive medications before they can access more costly treatments. While this might seem reasonable from a cost-savings perspective, it often creates unnecessary delays, and never questions why a patient failed the prior treatment.

The reality is that these tools often serve as financial mechanisms for insurers. In fully insured models, the more care they deny, the more money they save. Even when ideally using a transparent PBM model, these mechanisms aren’t identifying alternative solutions, missed steps in care or simply collaborating with the providers themselves.

The Disconnect: Insurers and Providers Are Not Aligned

One of the biggest issues I see is the lack of alignment between providers and payers. Providers are responsible for the patient’s immediate care but are often not held accountable for long-term outcomes or overall cost-effectiveness. On the other side, insurers may have financial incentives to limit care.

What happens when a medication is denied? Is there a clinical team that steps in to help find an alternative solution? The answer, unfortunately, is no.

This lack of communication and alignment creates inefficiencies and frustration for everyone involved—most importantly, for the patient.

The Path Forward: A Need for More Collaboration and Innovation

Ultimately, the goal is to find better ways to align the interests of providers, payers, and patients. While prior authorizations and step therapy may have started as well-intentioned mechanisms to control costs and ensure proper care, they need to evolve. We should move beyond “yes or no” decisions and embrace a more collaborative approach where insurers, vendors and providers work together to find the most effective treatment options for patients.

We need systems that allow providers to focus on delivering quality care, with vendors and systems in place to augment this, not make it harder.

What we really need? To incentivize cost savings for all involved.

Conclusion:

Healthcare is an ecosystem. No one party holds all the answers, and no one party should be making decisions in isolation. Our current system needs to embrace collaboration, innovation and flexibility if we want to improve both patient outcomes and the experience of healthcare professionals.

I’d love to hear your thoughts on this. Are prior authorizations helping or hindering your practice or experience? Let’s continue the conversation.

Thanks for reading and be on the lookout for the next issue.

Ryan Garner, PharmD.