Very kind of you, Pete, to say that. I'm touched. You will receive a certificate in the mail shortly good for a free lower GI endoscopy here in the USA. AKA, thank you.
In my experience, managed care and insurance companies are very careful not to tell doctors what to do. Otherwise they would be making medical decisions, and therefore be on the hook for the liability generated by the consequences of those decisions, as I understand it.
So they just refuse to pay for certain things that in their opinions don't work. Now- some of those financial pressures are based on the best evidence available- for example, bone marrow transplant therapy for recurrent breast cancer, which hasn't been shown to relieve suffering, prolong life in patients, or cure anyone. And it is very expensive. Insurance companies and managed care organizations tend to target expensive therapies which don't have a solid evidence base. Of course, as time goes on, some of those therapies WILL accumulate an evidence base which supports their efficacy. But by delaying and stalling, the insurance companies will have at least spared themselves having to pay for some of those treatments. Really for them it is about nothing other than the bottom line. Period, that's it.
This kind of maneuver, of course, leaves the patient with a lot of debt, and the physician or hospital with no payment, etc etc. The insurance company simply steps out of the middle and leaves the other players to fight it out.
Arguably, the kind of huge financial pressure they bring to bear really DOES constitute indirect medical decision-making. At least I think it does. But, at least at our hospital, we have a lot of patients trying to get in for inappropriate reasons, and frankly I welcome a situation in which social service or utilization review comes to the ER and tells us that the patient can't be admitted, but they will help make other arrangements. As long as the patient gets taken care of, it's fine with me.