Modern medicine likes clean categories. Herniated disc. Cervical stenosis. Postoperative recovery. For insurers, those labels make care predictable, measurable and easier to price.
For patients, however, that black-and-white approach often misses the mark, said Jeffrey Wang, MD, who sees its drawbacks daily as chief of orthopedic spine service and co-director of the Spine Center at the University of Southern California in Los Angeles.
Payers, Dr. Wang explained, have little choice but to organize care around diagnoses. The problem begins when those categories harden into rigid rules that fail to account for how differently the same condition can manifest in even just two people.
“They don’t account for a lot of the patient’s variability and the specifics of that patient,” Dr. Wang said.
As a spine surgeon treating complex cervical and lumbar disease, he sees that mismatch firsthand. Two patients may carry the same diagnosis on paper, but in practice, one may be stable, while the other is actively losing function.
“You’ll hear, ‘Most patients with this get better with physical therapy,’” he said. “But I’m seeing a patient who’s developing weakness and losing function in their hand.”
Despite that progression, coverage pathways often default to averages. Physical therapy comes first; advanced imaging is delayed; and interventions are postponed, even when time matters and loss of function is already evident.
In many cases, Dr. Wang said, insurers will not approve MRI or other advanced imaging early in the course of care. Appeals are possible, but they consume time and energy that could otherwise be spent treating the patient.
Peer-to-peer reviews are designed to bridge those gaps. Sometimes they do. Other times, they seem more like a formality with a predetermined outcome.
“We just have to have this call,” Dr. Wang said, recalling conversations where approval was never actually on the table.
When averages meet medical complexity
That dynamic does not end in the clinic. It follows patients into surgery and recovery, where standardized assumptions collide with medical complexity.
Procedures may be approved as outpatient care based solely on diagnosis, Dr. Wang said, even when a patient’s comorbidities make same-day discharge unsafe. Diabetes, bleeding disorders and frailty complicate recovery in ways no average can fully capture.
Even when physicians admit patients appropriately, payment is not guaranteed.
“They’ll say, ‘Go ahead and admit them if you need to,’” he said. “But they still won’t pay for it.”
That contradiction, he said, puts physicians in an impossible position: deliver the care they know is right, then fight to justify it later.
When the system rewards the average
At the heart of these conflicts is a healthcare system increasingly built around efficiency and predictability. Bundled payments and value-based models rely on averages, rewarding providers who can deliver consistent outcomes at scale.
Dr. Wang does not absolve physicians or health systems of responsibility. In many cases, he said, they have opted into those arrangements willingly.
“We’re playing the numbers,” he said.
Health systems accept lower, fixed payments based on typical outcomes, absorbing the costs of patients who require more care. Over time, that agreement becomes precedent. If providers accept averages, insurers assume averages are sufficient.
“That’s the environment we live in,” Dr. Wang said.
Why outcomes resist prediction
The flaw in that logic, he said, is that recovery is not purely biological. It is shaped by personality, psychology and circumstance, factors that rarely appear in coverage guidelines.
Some patients bounce back quickly from minor procedures, while others struggle disproportionately, but neither response is “wrong.”
Beyond mere physiology, social realities are at play. Transportation, caregiving responsibilities, work schedules and home support often determine whether discharge is safe.
“I can’t physically force the patient out,” Dr. Wang said.
That tension is heightened by patient satisfaction metrics, which place physicians between insurers demanding efficiency and patients expecting individualized care.
“If you just do what the insurance company says,” he said, “you can easily poison that relationship with patients.”
Where Dr. Wang draws the line
For Dr. Wang, the conflict ultimately resolves in one direction. He will not compromise patient care to satisfy administrative metrics.
“One thing I won’t compromise is I’m going to take care of my patients,” he said. “That’s why I got into this. I’m a doctor.”
He accepts that doing so may hurt performance metrics or increase costs. But he sees no alternative that aligns with his professional responsibility.
“I have to exist in this system,” he said. “That’s the hard part.”
What he would change
When asked what he would ask payers to change, Dr. Wang described a solution that is conceptually simple and operationally difficult: pay for the care patients actually need.
People pay premiums expecting coverage when illness strikes. The system strains when approvals are dictated by averages rather than individual outcomes.
“Just pay for the healthcare,” he said.
Delays in rehab authorization and extended hospital stays often stem from payment structures that reward delay. Once a hospitalization is paid for, additional days cost insurers nothing, but approving post-acute care does.
“If people need the extra time and it’s going to make them better,” he said. “Pay for it.”
The patient caught in the middle
Dr. Wang is aware that insurers face real challenges, such as unnecessary utilization, cost containment and more. But when safeguards become barriers, it’s the patient who suffers.
“The guidelines meant to prevent misuse are also keeping people from getting the best care they could or should get,” he said.
In a system built around efficiency, the individual can quietly be overshadowed. Dr. Wang’s frustration is not rooted in blame, but in a conviction that medicine’s gaze must remain fixed on the person behind the diagnosis, even when the system makes that difficult.
