Matt dives into a specific healthcare topic to help those in the industry, and those outside of it, better understand the market drivers causing today’s healthcare challenges.

I learned how the healthcare system really works from two angles most people never see together.

First, as a pharmaceutical industry executive watching insurance companies block patients from newer, better medications in favor of older generics. The reason was simple: profit.

Then as a patient fighting for a spinal cord stimulator to treat chronic pain. This was during the opioid epidemic—when insurance companies were publicly positioning themselves as part of the solution.

They denied my request and kept me on opioids instead.

For 18 years.

My physician submitted a prior authorization request for the spinal cord stimulator. Denied.

He appealed. Denied again.

He requested a peer-to-peer review—the supposed safeguard where one physician discusses the case with another. This is where the system reveals itself.

The insurance company's "peer" was an ex-OBGYN. No spinal experience. No pain management background. He wasn't evaluating my case based on medical expertise.

He was reading from the insurance company's medical policy script.

This isn't peer review. It's theater designed to create the appearance of medical oversight while protecting profit margins.

Research confirms what I experienced: 58% of insured adults who needed specialized care faced delays or denials. Even more damning: 29% of physicians reported prior authorization led to serious adverse events including hospitalization, life-threatening complications, or permanent damage.

Insurance companies can't legally practice medicine. So they created a workaround.

They hire physicians to write "medical policies" that override your doctor's judgment. When an ex-OBGYN denies a spinal specialist's treatment recommendation, the insurance company claims they're just following medical policy.

But who wrote that policy? The insurance company's own hired physicians—selected and compensated to prioritize cost containment.

My physician carried malpractice insurance. He bore legal liability for my outcomes. The insurance company physician reading from a script? Zero liability.

Responsibility and authority are completely separated.

This destroys the physician-patient relationship. Patients don't know who to trust. Their doctor recommends treatment A. The insurance company—through a physician with no relevant expertise—mandates treatment B.

How are patients supposed to navigate that? They're not doctors.

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Physicians watch medical technology advance. They understand new pharmaceutical products, side effect profiles, and patient-specific needs that insurance companies ignore.

They know better treatments exist. They watch their patients suffer with adequate care when ideal care is available.

The insurance companies block access anyway.

A Senate investigation revealed that UnitedHealthcare and CVS denied prior authorization for post-acute care at three times their overall denial rate. Humana's denial rate for post-acute care was 16 times higher than its overall rate.

They deliberately target expensive but necessary treatments to maximize profit.

Population-level data might show "adequate disease management." But that data misses the lived experience of patients denied medications that would eliminate side effects or improve quality of life.

Why should patients suffer with adequate when they can get ideal?

Insurance companies have redefined success. It's no longer about helping you thrive. It's about keeping you alive while spending as little as possible.

This creates a perverse cycle.

When you receive adequate care instead of ideal care, you keep searching for what you actually need. More appointments. More interventions. More emergency care when conditions worsen because preventive treatment was denied.

I had dozens of procedures that added no value to my health but were allowed by insurance. Meanwhile, opportunities for better care were blocked, forcing me onto opioids that created comorbid conditions—anxiety, depression, and more—that drove up my costs exponentially.

Research validates this pattern: 88% of physicians report that prior authorization requirements force patients to seek additional office visits, immediate or emergency care, or hospitalization.

The profit-from-denial model is economically irrational in the long term.

But insurance companies aren't optimizing for long-term patient health. They're optimizing for Wall Street quarterly reporting.

Most people think they're buying health protection when they pay insurance premiums.

You're actually funding investment portfolios.

Insurance companies are banks that penalize you for making withdrawals. They use your premium dollars for their own business ventures and investments. When you actually need care, you're cutting into their ability to grow profits for Wall Street.

The numbers prove it. The seven largest publicly traded U.S. health insurance companies reported combined profits of $71.3 billion in 2024—a new record. Their CEOs collectively earned $146.1 million.

While patients ration care.

The Medical Loss Ratio requires insurance companies to spend 85% of premium dollars on "medical expenses." Sounds reasonable until you realize what counts as medical expenses: administrative costs, denial management, utilization review, marketing, and executive salaries.

Not 85% on actual patient care. 85% on a category designed to obscure how little reaches patients.

You can't solve this through individual choice because real choice doesn't exist.

Three companies dominate American healthcare. They own the insurance, the pharmacy benefit manager, the specialty pharmacy, and the retail pharmacy. Vertical integration that eliminates competition.

They control how you access the system at every point.

This isn't a free market. It's a pseudo-market where the same entities own every layer of the supply chain. When companies profit from denying care at the insurance level, approving expensive medications at the PBM level, and dispensing at the pharmacy level, they optimize the entire system for their benefit.

Not yours.

Real market competition would require breaking up these monopolies. Different types of plans, different risk pools, different offerings that actually compete on value to patients.

Healthcare executives think they listen to patients when they collect feedback surveys.

That's not listening. That's checking a box.

The lived experience of patients is the most valuable data set available. You can understand the medical condition, the barriers to care, and the real-world impact if you actually speak with patients and allow them to share.

When you help patients reach their health goals—not just "adequate management"—you reduce spending. When you keep care adequate, patients continue seeking the ideal care they need in their hearts.

More appointments. More interventions. Higher costs. Worse outcomes.

If healthcare leaders changed incentives to focus on true patient health instead of managed sickness, we'd see longer appointment times, better satisfaction scores, better outcomes, and lower overall spending.

But that requires treating patient experience as strategic intelligence instead of background noise.

The current system reveals a fundamental incompatibility between market-based insurance models and universal care goals.

Insurance companies generate revenue by withholding services they're designed to provide. That inverted incentive structure corrupts medical decision-making, shifts power from physicians to financial gatekeepers, and transforms healthcare into a reactive, emergency-based system that costs more while delivering less.

Meaningful reform requires:

Breaking up the big three monopolies. Vertical integration eliminates competition. The government must separate insurance from PBMs, pharmacies, and provider networks.

Redefining the Medical Loss Ratio. 85% must mean 85% on actual patient care—not administrative expenses that include denial management and executive compensation.

Creating liability for coverage decisions. If insurance company physicians override treating physicians, they should carry malpractice liability for outcomes.

Centering patient lived experience. Population-level data obscures individual suffering. Strategic decision-making must incorporate patient voice as primary evidence.

Realigning incentives toward health, not managed sickness. The system currently rewards keeping patients in adequate states that require ongoing intervention. True value comes from helping patients reach their health goals.

This doesn't have to be this way.

I spent 18 years on opioids because an insurance company valued quarterly profits over my health. Those years created comorbid conditions that multiplied costs and destroyed quality of life.

Dozens of procedures added no value but were approved. The one intervention that could have changed everything was denied.

That's not healthcare. That's financial extraction disguised as medical necessity.

The next generation of patients deserves better. Healthcare leaders and policymakers need to understand what they're currently blind to: the patient voice isn't noise to be managed.

It's the signal that reveals where the system fails.

And right now, it's failing by design.

Join me with Matthew Zachary, Sally Neely Nix and others as we kickoff our first of many live events for We The Patients in Raleigh-Durham, NC. For more information, check out the EventBright page below.