Rethinking Health Care Decision-Making
In outpatient medicine, things happen fast. A doctor sends a prescription to the pharmacy, refers a patient to a specialist, and orders tests—all of this feels immediate for patients, who believe care is moving ahead.
However, this is often just the start of a longer journey. Days or even weeks later, the process circles back. The pharmacy might call because the medication needs prior approval. Insurance companies review papers for claims, and referrals often trigger requests for more information about the necessity of the service.
Despite the patient’s condition remaining unchanged and even perhaps improving, the healthcare system begins reassessing previous decisions.
As time goes on in medical practice, a pattern emerges: decisions aren’t simply processed as they happen; they are often revisited later. A significant amount of healthcare administration is devoted to verifying the legitimacy of decisions long after they have been made.
You can see this pattern almost everywhere in the system. Claims are denied weeks after the service is provided. Hospitals revisit patient charts months later. Audits occur long after treatment has taken place. Regulators examine records years later—all aiming to answer the same crucial question: Was the initial decision justified?
This routine can appear inefficient from the outside, but within the healthcare system, it reveals a deeper issue. While healthcare is adept at documenting events through electronic records, it rarely confirms whether decisions are valid in real time. Instead, it relies on audits, reviews, and appeals much later in the process.
We can think of this as a reconstruction phase in healthcare, where a separate system kicks in to check if decisions made earlier followed the rules. This process involves various teams, including utilization management, coding specialists, claims auditors, and compliance departments, all working to reconstruct the situation surrounding previously made decisions.
For both doctors and patients, the consequences of this system are familiar. A patient leaves a clinic assuming they can collect their medication, only to find out approval is still pending. A referral to a specialist sparks requests for information on decisions already made. Likewise, a claim submitted weeks earlier may be denied due to a different interpretation of the records.
These issues don’t change the original moments of care but create a system that spends considerable effort revisiting those moments. This is one reason administrative costs in American healthcare remain high, despite advances in digital technology. Healthcare isn’t just processing transactions—it is reevaluating them repeatedly.
With the introduction of artificial intelligence (AI) in healthcare workflows, many hope to reduce the administrative burden through automation. While this can be beneficial, it won’t eliminate the structural problem of delayed legitimacy assessments. If healthcare continues to rely on reconstructing past actions, new technologies may only speed up the decision-making process without addressing when those decisions can be trusted.
In contrast, other industries, like finance, settled similar challenges long ago. Once a trade occurs, it is accepted without reopening questions about its legitimacy. Healthcare, however, evolved differently. It captures detailed records but often delays validating decisions, leading to the complexity that both clinicians and patients face today.
To move forward, healthcare needs to shift some of the validation work closer to when decisions are made. Instead of relying heavily on post-event reviews, the aim should be to align documentation and authorization in real time—making the process smoother and more efficient.
Without this change, the future looks like more of the same: quicker decisions followed by layers of retrospective reviews—continuing a trend of looking back, even as everything else accelerates.
Holland Haynie, M.D., is a family physician and chief medical officer at Central Ozarks Medical Center in Missouri.
