For the first time, I have started to wonder whether healthcare will survive the disruptions and middlemen that are invading what was sacrosanct space between the physician and their patient. It seems so many organizations are more interested in treating patients as pawns in a race for grabbing every possible dollar of profit—without regard for the patient, their disease, the quality of their lives, and their work and family concerns.
Health Insurance Added Complexity to Healthcare Delivery
Social insurance was endorsed early in 1912 at the national and state level, including concepts for health insurance models and regulation. Other models emerged and were considered over the next 2 decades, including a 1929 Baylor Hospital prepaid insurance plan—considered the precursor of future Blue Cross plans. The Great Depression of the 1930s increased the need for social policies to secure employment, retirement, and medical care. President Roosevelt’s 1944 Economic Bill of Rights included the right to adequate medical care and the opportunity to achieve and enjoy good health. Employer-based health coverage offerings grew, and by the 1960s, private plans set premiums based on their healthcare cost experience. Nonemployed people found it difficult to find affordable coverage. Medicare and Medicaid programs were signed into law in 1965 as part of the Social Security Act. In 1972, the Employee Retirement Income Security Act exempted self-insured employers from state health insurance regulations. By 2010, the Patient Protection and Affordable Care Act was passed requiring that all individuals have health insurance by 2014—but the individual mandate in that bill was removed in 2016 by the next president. The COVID-19 pandemic led to a hard look at healthcare access and utilization. Despite all these reforms, both insured and under- or uninsured people experience barriers to access care.1 With the creation of health insurance plans, patients became more removed from the financial costs of care as care was becoming more complex, and innovation expanded equipment, specialization, and drug and medical options far beyond our wildest imagination.
Insurers, in their effort to control costs, have prioritized short-term denials over long-term value and positive health outcomes, undermining their own credibility while failing to promote their own customers’ well-being.
Middlemen Entities Aggressively Entered the Healthcare Space
We have come so far from the local physician who made house calls and was paid in cash or goods. Now, it seems that no matter what a doctor prescribes, there is no shortage of external opinions as to whether that choice was appropriate. Some seek to shape the medical choices even before the patient has been seen, through pathways and healthcare/practice policy, or internet/family opinions influencing the patient. Others, usually health plans, pharmacy or medical benefit managers, among many others, seek to deny or second-guess the physician despite no access to the patient, their history or their medical situation/needs through prior authorization, step edits, claims reviews and denials, and even derailing treatment access for profiteering (see prior OPM editorial commentaries on alternative funding programs and copay accumulator models). These intermediaries supposedly originated to help providers, patients, and employers navigate the new complexities of billing, selecting insurance plans and benefits, and negotiating drug prices. However, these middlemen have instead created their own costly intrusion into healthcare, becoming obstacles to progress, collecting revenues without contributing direct value to the patient’s outcomes, adding fiscal, operational and delay barriers to healthcare and in general perpetuating inefficiencies and add costs in ways that exacerbate the problems in the healthcare system.2
It is starting to sound as though patients do not matter any longer.
Middlemen intrusion is often more likely to harm the patient and their medical condition, rather than help, and place significant, corporate medical decision-making obstacles as a replacement for the traditional physician/patient-based medical decision-making. Horizontal and vertical integration of health plans, pharmacy benefit managers (PBMs), and specialty pharmacies have consolidated markets so that the 3 largest PBMs (all owned or closely aligned to health plan insurers) control 80% of all prescriptions in the United States, encouraging profit extraction and rising prices that create a significant financial burden for both employers and employees.
Barriers to Care Are Proliferating, Not Improving
High deductibles, cost-sharing, and utilization management, such as prior authorizations and step edits that reduce access to treatments and care, continue to proliferate despite all the attempts to secure or provide health insurance for the public. Rita Numerof wrote in Forbes recently about the failure of the utilization management system in healthcare: “Insurers, in their effort to control costs, have prioritized short-term denials over long-term value and positive health outcomes, undermining their own credibility while failing to promote their own customers’ well-being. Under the current business model, insurance companies make more money the more claims they deny or through favorable drug formulary positioning and rebate demands from manufacturers, regardless of the individual patient health needs. When patients get sick or in extreme cases even die because care was denied or delayed there is little impact for the insurer.”3
Are We Reaching the Tipping Point?
There is growing recognition among federal and state agencies and legislatures that the intrusion of middlemen, and their uncontrolled vertical and horizontal integration has led to higher costs, reduced access to care, and unsustainable financial and administrative burdens on providers, patients, and employers. Congressional committees, federal agencies, and individual states have heightened their scrutiny and calls for reform, particularly related to the PBMs, but also the intrusive copay accumulators and alternate funding program models chasing self-insured employers. The Federal Trade Commission released a January 2025 report finding that PBMs charge significant markups for cancer/HIV and other critical specialty generic drugs.4
When did we get to the point where practices now routinely request prior authorization for almost every procedure or treatment—and hire staff just to track what will be allowed or not for different payers, where highly trained physicians are reduced to asking “mother, may I.” None of those utilization management barriers pay attention to the actual medical history and needs of the patient—it has simply become a game of algorithms and box checking. I am even hearing reports of health plan denials coming back to the practice marked “Can Not Appeal,” thereby blocking any chance for the treating physician to explain why the denied service was necessary for the patient. It is starting to sound as though patients do not matter any longer – we have lost the vision for treatment and outcomes, ironically, at a time when physicians are being challenged at every step to provide and prove “value-based care.”
This is the time to track our successes, and to document the failures of the intruders.
I believe there is hope at the end of the tunnel. That the exorbitant profits being drained from the healthcare system by intrusive middlemen that do not actually contribute to the diagnosis or treatment of patients are actually being recognized and seen as the valueless burden that they are. I have seen at least one state propose legislation that utilization management organizations must presume from the start that any service or treatment prescribed or ordered by a physician (board certified in a relevant specialty) shall be considered medically necessary. Challenges coming from the utilization management company must seek to “prove” that physician’s orders are not medically necessary and not be just allowed to state their opinion and refuse to cover the service. We have the rise of medical use of massive amounts of care data, growing technology to distill that data into diagnostic and decision support tools, and an interest in the medical community to leverage technology to overcome the massive amounts of relevant clinical information that is out there. We can support trained physician decision-making with new information and distillation of real-world data into managing patient detection, management, and successful outcomes. But that role cannot be handled by external parties without knowledge of the patient.
What Can Practices Do?
With all the chaos and information about the cost burden of external parties’ intrusion in the healthcare space, this is the time to speak to the truth and simplicity of physician medical decision-making. The benefits of technology, algorithms, and eventually artificial intelligence in managing massive amounts of data and medical information still belong in the hands of treating physicians, not corporate middlemen. This is the time to track our successes, and to document the failures of the intruders. When you see patients being harmed or delayed in care, and adversely impacted by a middleman by policy, patient control, or even abuse of algorithms in place of human medical decision-making, there are now state and federal agencies that will want to hear those stories. We cannot allow our patients to lose access to the care they need because an intruder wants to treat them as a pawn for profit.
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Reference
- Smith K. A (brief) history of health policy in the United States. Delaware J Public Health. 2023;9:6-10.
- Pearl R. The costly failures of medicine’s middlemen. Forbes. Accessed May 20, 2025. www.forbes.com/sites/robertpearl/2024/10/28/the-costly-failures-of-medicines-middlemen/
- Numerof R. 2025 improve or dismantle: utilization management is broken – fixing it requires a new business model. Forbes. Accessed May 20, 2025. https://www.forbes.com/sites/ritanumerof/2025/02/24/utilization-management-is-brokenfixing-it-requires-a-new-business-model/
- Federal Trade Commission. FTC releases second interim staff report on prescription drug middlemen. Accessed May 20, 2025. www.ftc.gov/news-events/news/press-releases/2025/01/ftc-releases-second-interim-staff-report-prescription-drug-middlemen