A physician who wrote a book on health insurance still could not get his own cancer treatment approved. Dr. Ben Proctor explains why care gets denied and who profits.

Dr. Derrick Hines sits down with Dr. Ben Proctor, a physician and the author of Inefficient on Purpose, to talk about how for-profit health insurance shapes the care patients actually receive. They cover how insurers use prior authorization to deny tests and treatment while keeping the premium, why tying insurance to your job makes it so hard to switch, how pharmacy benefit managers (PBMs) and rebates push drug prices up, and why doctors cannot push back the way other workers can. Ben shares patient stories, his own experience as a leukemia (CML) patient whose treatment was delayed by a denial, and the changes he believes would actually fix the system.

Key Takeaways
-- The US spends far more on health care per person than peer countries, about $14,775 against a peer average of around $7,800, yet ranks last of ten wealthy nations on access, outcomes and administrative efficiency, according to the figures Derrick shares.
-- Ben explains that health insurers profit by denying care through prior authorization: a requested MRI or CT scan is refused and the insurer keeps the premium.
-- Because most Americans get insurance through their employer, switching plans after repeated denials often means changing jobs. With premiums rising and deductibles of $5,000 to $10,000, more people are cancelling coverage or paying cash. In Derrick's clinic, cash-pay patients grew from 3 to 5 percent when he opened 13 years ago to 20 to 25 percent today.
-- The three biggest pharmacy benefit managers are owned by the three biggest health insurers, and Ben describes the rebates drug makers pay them as paying to play.
-- A denial delayed Ben's own leukemia treatment by six weeks in 2025, and his cancer came back. He cites surveys finding that about one in three doctors has seen a denial lead to a worse outcome for a patient.
-- His central question is whether health insurance should be run for profit at all. In his words, "the goal of healthcare is not to make profit, it's to make people better." He favors realistic reforms such as capping insurer profits, limiting premium increases and letting doctors practice medicine.

Questions Answered
-- Why does health insurance deny tests like MRIs?
-- What is prior authorization and how does it affect patients?
-- What are pharmacy benefit managers (PBMs)?
-- Why does the US pay more for health care and get worse outcomes?
-- What can patients do when their insurance keeps denying care?

What You Can Do
If a test or medication you need keeps getting denied, Ben suggests looking for a different insurance plan the following year, and telling your representatives and lawmakers that you want change. His book Inefficient on Purpose is available on Amazon, with an audiobook planned for November.

DERRICK
Instagram: https://www.instagram.com/derrickbhines/
YouTube: https://www.youtube.com/@DrDerrick

BEN
Website: https://www.inefficientonpurposebook.com/
Book: https://www.amazon.com/dp/B0HJGBBTRC

#HealthInsurance #Healthcare #PriorAuthorization