As a rheumatologist, I witness firsthand how insurance formularies dictate patient care — often to the detriment of individualized treatment. This issue is not unique to rheumatology. It extends across multiple specialties, affecting access to critical medications for obesity, diabetes, and cardiovascular disease. Physicians are being forced to prescribe treatments dictated by insurance companies rather than by clinical guidelines, patient-specific needs, and FDA-approved indications.
We are at a pivotal moment in health care, where groundbreaking medications exist but remain out of reach due to insurer-driven restrictions. This system prioritizes cost-saving over clinical outcomes, ultimately exacerbating long-term health issues and driving up overall health care costs.
The Insurance Barrier to FDA-Approved Therapies
Consider the recent surge of GLP-1 receptor agonists, a class of medications revolutionizing the treatment of obesity and diabetes. Clinical trials have demonstrated their effectiveness in reducing cardiovascular risk, improving glycemic control, and promoting sustainable weight loss. Despite these proven benefits and FDA approval, many insurers refuse to cover these medications for obesity treatment, citing cost concerns or categorizing obesity as a “lifestyle issue” rather than a medical condition.
Similarly, in rheumatology, patients with autoimmune diseases such as lupus, rheumatoid arthritis, and psoriatic arthritis frequently encounter formulary restrictions. Physicians are often required to prescribe older, less effective, or non-FDA-approved medications before gaining access to newer biologics with superior safety and efficacy profiles. This process, known as step therapy or “fail first,” can lead to prolonged disease activity, irreversible joint damage, and reduced quality of life.
The Disconnect Between Clinical Guidelines and Coverage
The contradiction between clinical guidelines and insurance coverage is glaring. Professional societies, such as the American Diabetes Association, the American College of Rheumatology, and the American Heart Association, provide evidence-based recommendations for medication use. Yet, insurers routinely disregard these guidelines, forcing patients and physicians into bureaucratic battles for necessary treatment.
For example, a patient with psoriatic arthritis may need a targeted biologic to prevent disease progression, yet their insurer mandates a trial of methotrexate — even though clinical data suggest that methotrexate is less effective in psoriatic arthritis. Similarly, a patient with obesity-related heart disease may benefit from a GLP-1 receptor agonist, but their insurer denies coverage unless they have a diabetes diagnosis, despite the medication’s proven cardiovascular benefits.
The Financial and Emotional Toll on Patients
These insurance-driven restrictions do not just delay care; they create an overwhelming burden on patients. The financial strain of paying out of pocket for noncovered medications can be insurmountable. Some patients resort to rationing their medications, skipping doses, or forgoing treatment altogether — decisions that lead to worsening disease and preventable hospitalizations.
Beyond the financial aspect, the emotional toll of navigating insurance denials is significant. Patients place their trust in physicians to provide the best possible care, yet they often find themselves caught in a maze of prior authorizations, appeals, and denials. This process is frustrating, demoralizing, and, in many cases, medically harmful.
The Cost of Short-Sighted Policies
Insurance companies often justify restrictive formularies as cost-containment measures, but these policies fail to recognize the broader financial impact. When patients are denied optimal medications, their conditions often worsen, leading to increased ER visits, hospital admissions, and complications that require more expensive interventions.
Preventative medicine is key to reducing long-term health care costs, yet insurers continue to operate in a reactionary model — one that denies access to proven treatments until a patient’s condition deteriorates to a costly and avoidable crisis.
For instance, denying GLP-1 receptor agonists for obesity treatment might save insurers money in the short term, but it ignores the downstream effects: increased rates of cardiovascular disease, stroke, and uncontrolled diabetes, all of which lead to higher long-term health care expenditures. In rheumatology, delaying access to biologics means patients accumulate irreversible joint damage, requiring joint replacements or long-term disability support — costs that far exceed the expense of early, appropriate intervention.
The Physician’s Perspective: Forced To Fight for Care
As physicians, our job is to provide the best care possible based on scientific evidence and our patients’ individual needs. Yet, we increasingly find ourselves spending valuable time fighting insurance denials rather than practicing medicine. Prior authorizations, peer-to-peer reviews (that occur often outside of our own specialties), and appeal processes have become routine administrative burdens, pulling us away from patient care and contributing to burnout.
This system is not only inefficient but also deeply flawed. Many so-called “peer reviewers” employed by insurance companies lack expertise in the specific conditions they are evaluating. Rheumatologists find themselves justifying treatment decisions to insurance reviewers who have no training in autoimmune diseases. Endocrinologists advocating for GLP-1 receptor agonists must debate with physicians who may have no background in obesity medicine. This disconnect between expertise and decision-making is a glaring flaw in our current system.
What Needs To Change?
1) Mandating Coverage for FDA-Approved Indications: If a medication is FDA-approved for a condition, insurers should not have the power to arbitrarily deny coverage based on cost-saving strategies. Coverage should align with clinical guidelines, not insurance profit models.
2) Eliminating Nonmedical Switching and Step Therapy for Chronic Diseases: Patients with complex diseases should not be forced to fail on inferior treatments before receiving the most effective options. Step therapy policies should be reformed, especially when there is clear clinical data supporting first-line use of a specific medication.
3) Increasing Transparency in Formulary Decisions: Insurance companies should be required to publicly disclose the rationale behind formulary exclusions and restrictions. Patients and physicians deserve to know whether medical evidence or financial incentives are driving coverage decisions.
4) Reducing Administrative Burdens: The prior authorization process should be streamlined, with automatic approvals for medications meeting guideline-based criteria. Physicians should not have to justify the same treatment decisions repeatedly for chronic, well-documented conditions.
5) Expanding Preventative Medicine Coverage: The U.S. health care system needs to shift from treating advanced disease to preventing it. Medications that reduce long-term health risks, such as GLP-1 receptor agonists for obesity and cardiovascular disease, should be prioritized rather than excluded.
The Path Forward
If we want to improve health care outcomes in the U.S., we must stop allowing insurance formularies to dictate medical decisions at the expense of patient health. The current system places undue strain on patients, physicians, and the health care system as a whole. By reforming medication access policies, we can move toward a system that values prevention, prioritizes evidence-based care, and ultimately reduces the long-term financial burden of chronic diseases.
Physicians and patients must continue to advocate for these changes. Whether through policy reform, legislative efforts, or public awareness, we must push back against a system that prioritizes short-term savings over long-term health. It’s time for insurers to stop playing gatekeepers to the care that patients need and for health care policy to align with the principles of individualized, evidence-based medicine.
How do you push back against insurer-driven treatment restrictions? Share in the comments.
Dr. Brittany Panico is a rheumatologist in Phoenix, AZ. She is a wife and mother of three awesome boys and enjoys hiking, being outdoors, traveling, and reading. She posts on @AZRheumDoc on Instagram and Brittany Panico, DO, on LinkedIn. Dr. Panico was a 2023–2024 Doximity Op-Med Fellow and continues as a 2024–2025 Doximity Op-Med Fellow.
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