Transparency is a healthcare buzzword used in a number of broad contexts, but frequently appears in discourse about the relationship among physicians, payers and patients.
"I think transparency can be about the health insurance structure and what that means when patients have tests and treatments that need prior authorization from their insurance company," said Carla LoPinto-Khoury, MD, a professor of neurology at Temple University in Philadelphia.
Prior authorization is a significant area where physicians have urged for more transparency on payer processes and decision-making. According to Medscape's "'They're Awful and Impede Patient Care': Medscape Physicians and Prior Authorizations Report 2024," 73% of physicians said that they could not "learn relatively quickly" whether a patient's health plan would require a prior authorization for certain treatments or medications. Another 86% said that prior authorizations interfered with a patient's care or treatment plan.
Dr. LoPinto-Khoury said that these interferences can often stem from a breakdown in communication, and therefore lack of transparency, between physicians and insurers during the prior authorization process.
"The insurance company may deny a test or a treatment, claiming that the doctor did not provide enough information when in fact the doctor's office sent all the notes but the fax machines are set to only receive five pages," she said. "But as physicians we get these denials all the time and patients are falsely led to believe that their insurers are in fact reading what we send them and when we physicians do speak to medical reviewers — when they do not bounce us around on their phone trees for 30 minutes on purpose — they are not even qualified professional and do not care to engage in any discussion."
A recent survey by the American Medical Association found that 85% of physicians do not see payer-appointed medical reviews as "peers" at all. The disruption that this creates in patient care creates further lapses in transparency between physicians and their patients.
"The patients are led to believe that their physicians are in charge of their care when in reality the health insurers have the final say on what the patient can get," Dr. LoPinto-Khoury said.
Reimbursement rates are another area where physicians desire more transparency, as commercial payers often follow Medicare guidelines for physician reimbursements, but the processes for deciding those reimbursements are often opaque to physicians.
"It's almost like there was a very antagonistic relationship when people would [complain] at me, their doctor, about their co-pay for something," Susan Baumgaertel, MD, an internal medicine physician in Seattle, told Becker's. Dr. Baumgaertel practiced at The Polyclinic in Seattle for 25 years, where she also had an ownership stake, before launching her independent telemedicine practice, myMDadvocate.
She frequently encountered patients who expressed frustration about having to pay co-pays in addition to their health insurance premiums. The lack of clarity surrounding how reimbursement rates are set, and the destination of co-payments, often led to friction during billing.
"I said [to patients], this has nothing to do with me. I have no control over the fact you have to pay 20 bucks for this visit. That is between you and your insurance company," Dr. Baumgaertel said. "They looked at me like I was evil. I don't get 20 bucks from your visit. I felt like, if you get a buck, you know, they would look at me."
This dynamic has created a cycle where patients, frustrated by unexpected charges for services believed to be covered under their insurance, direct their dissatisfaction toward physicians. With limited access to the entities setting reimbursement rates, physicians often become the default target for patients' frustrations.