When I first began practicing medicine, discussing finances and insurance with patients was often considered taboo. Today, that approach no longer serves patients well. Transparency, integrity, and education are now essential parts of high-quality medical care. As physicians, it is our responsibility to help patients understand both the benefits and limitations of health insurance so they can make informed decisions about their health.
Reframing How We Think About Health Insurance
One of the most important mindset shifts we can make is to think of health insurance similarly to car insurance. Car insurance is designed to protect you in the event of a major accident or crisis. It is not meant to cover routine maintenance, oil changes, or standard wear and tear.
Health insurance functions much the same way. It is most effective for:
Emergency room visits
Hospitalizations
Major surgical procedures
Serious or complex illnesses such as cancer
Expecting insurance to fully cover every diagnostic test, treatment, or preventive intervention is increasingly unrealistic in today’s healthcare environment.
The Reality of Insurance Decision-Making
Most private health insurance companies are for-profit businesses. Their primary objective is financial sustainability and profitability. While patient health may benefit along the way, insurance companies are not staffed by physicians who treat patients daily, nor are they deeply involved in interpreting evolving medical research in real-world clinical settings.
Government-sponsored plans, including Medicare and Medicare Advantage plans, often operate with similar limitations. While they are not structured as profit-driven entities, coverage decisions are still made through large bureaucratic systems that may not prioritize individualized care.
Why the Physician–Patient Relationship Matters More Than Ever
Over time, meaningful medical decision-making has gradually shifted away from the physician–patient relationship and toward insurance-driven approval processes. This has created the false assumption that if a treatment is covered, it must be the best option — and if it is not covered, it must not be effective.
That assumption is simply not true.
The highest-quality medical care occurs when physicians and patients work together as a team, customizing diagnostic and treatment plans based on the patient’s goals, values, and the best available medical evidence — not solely on insurance coverage.
A Common Orthopedic Example
In orthopedics, this issue arises frequently. For example, insurance companies will often continue to cover repeated steroid (cortisone) injections for knee osteoarthritis — even when excessive use can accelerate joint damage and worsen long-term outcomes.
At the same time, many insurance plans still label platelet-rich plasma (PRP) injections as “experimental,” despite more than 50 clinical studies demonstrating its effectiveness in treating knee osteoarthritis. Interventional orthopedic physicians are increasingly advocating for PRP to become a standard of care, as it addresses inflammation and joint health rather than temporarily masking symptoms.
Preparing Financially for Healthcare in 2026 and Beyond
With rising deductibles and limited coverage for many advanced diagnostics and treatments, patients should expect to allocate some funds for out-of-pocket healthcare expenses.
Just as you pay an auto insurance premium yet still cover routine maintenance and repairs, healthcare now requires a similar approach. Unlike vehicles, our bodies do not come with warranties.
As we move into 2026 and beyond, the most important step patients can take is to work closely with trusted physicians who prioritize your long-term health — even when insurance companies are not aligned with those decisions.
