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The killing of UnitedHealthcare executive Brian Thompson sent shockwaves through the medical community, Wall Street, and social media. The motive behind the killing appears to be obvious: the bullets were reportedly inscribed with the words “deny,” “defend,” and “depose,” phrases that refer to insurers’ common practices of denying care, defending their positions in court, and deposing those who challenge them.

Some social media commentators embraced the murderer’s rallying cry. I was sickened by those comments suggesting Thompson deserved his fate. Let me be clear: this killing was abominable. No one deserves to lose their life because of a business decision.

That said, many of the decisions insurers like UnitedHealthcare have made are, themselves, abominable. They do deserve our outrage. We can simultaneously be outraged at both Thompson’s killing and the immoral actions of insurance companies.

Take, for example, Anthem Blue Cross and Blue Shield’s recent decision to limit payment for anesthesia services. This policy would have limited payments based on CMS’ “physician work time values,” determination of how long a surgical case should take to perform. Such a policy is ludicrous. Surgeries, whether routine or complex, can often take longer than expected due to a variety of factors. Imagine a surgeon having to watch the insurance anesthesia clock while performing an organ transplant or removing a brain tumor. Thankfully, Anthem thought twice (following significant pushback) and reversed course.

But the Anthem policy is not an outlier. Insurers routinely use reimbursement policies to control medical care. They also use behavioral economics to influence, dictate, and restrict clinical decisions. These strategies undermine physicians’ ability to provide the best care for their patients, and they create a chilling effect that has real-world consequences — sometimes devastating ones.

The Tools of the Trade: How Insurers Dictate Care

Insurers use a variety of tactics to control healthcare decisions, all under the guise of cost management. But let’s be honest — “cost management” means more profit for private health insurers, and certainly not to the benefit of the healthcare system or patients.

One of the most questionable tactics has been prior authorization, which requires clinicians to obtain advance approval from an insurer before a treatment can be provided.

In 2018, several organizations representing healthcare providers and health plans set forth a plan to improve their prior authorization practices. Yet, a 2023 American Medical Association survey revealed most clinicians still believe prior authorization remains a major issue. In fact, 94% of providers surveyed said prior authorization still delays care. More than three-quarters (78%) reported that prior authorization has led to patients abandoning treatment, and 24% said prior authorization has led to a serious adverse event for a patient in their care.

Prior authorization is not the only strategy many insurers deploy. By setting unsustainably low reimbursement rates for certain treatments, insurers discourage providers from offering specific services. This tactic limits consumers’ choices, particularly when it comes to specialized treatments or therapies. Insurers also limit consumer and provider choice by routinely excluding certain treatments and shrinking the number of covered providers. On the back end, after care has taken place, insurers may deny claims, a tactic that causes mental anguish for patients and costs providers and administrators significant time.

Insurers also target patients directly. Indeed, some regularly comb through patient records for signs of “overutilization.” These reviews can result in additional denials and further traumatize patients, especially those with chronic conditions.

A final tactic is step therapy, or the practice of requiring patients to attempt less expensive treatments first, even if a clinician believes another option may offer a better outcome. This summer, government officials in New York negotiated a $1 million settlement with UnitedHealthcare for allegedly failing to cover all federally approved birth control without restriction. The company allegedly denied a patient coverage for a certain progestin-only oral contraception pill, forcing the patient to try alternative treatments, despite the fact that progestin-only contraceptives can be a good option for patients with certain health conditions.

Insurers argue these practices are necessary to control healthcare spending, but in reality, they can harm both patients and providers. Patients receive substandard care, or wait endlessly for care. Meanwhile, providers and their teams are burdened by endless paperwork, phone calls, and appeals. Insurers’ practices contribute to physician burnout and have even led physicians to abandon certain networks entirely.

What Needs to Change

The healthcare system should prioritize patients, not profits. Right now, it does not. That is one reason Gallup found Americans’ rating of the quality of the U.S. healthcare system is at its lowest point since 2001.

To reverse this decline, insurers must adopt policies that support, rather than hinder, care delivery. These policies include:

• Increasing transparency in reimbursement decisions;
• Aligning payment policies with evidence-based medicine;
• Reducing administrative burdens on providers; and
• Ensuring patients have access to timely and appropriate care.

The Anthem policy reversal is a small victory, but it is not enough. In an internal video message sent to employees on December 6, UnitedHealth Group CEO Andrew Witty appeared to defend his company’s policies. “Our role is a critical role, and we make sure that care is safe, appropriate, and is delivered when people need it,” Witty said. “We guard against the pressures that exist for unsafe care or for unnecessary care to be delivered in a way which makes the whole system too complex and ultimately unsustainable.”

To me, that statement sounds a lot like Witty is demonizing doctors. Should it really be the job of insurers (or AI used by insurers) to define what is unsafe or unnecessary? (Think again about the unintended consequences of limiting anesthesia and what that says about insurers’ care for safety.) Caregivers cannot let these sentiments or tactics stand. While condemning the crime committed last week — and the social media commentators who defended or celebrated the killing — physicians must advocate for systemic change. We must use our collective voice to demand a healthcare system where medical expertise — not financial incentives — drives care.

Until we do, the U.S. healthcare system will continue to fail the very people it is meant to serve.