We are familiar with the medical professionals, and even medical-adjacent professionals, who make healthcare decisions. These include doctors and nurses, but also hospital administrators and third-party payers. But we may not be aware of the vast number of non-medical professionals who play a role in medical decision-making, both in the field and off. In today's post, we will look at some of the professional fields that impact medical decision-making, and how those decisions impact your medical care.
Patients are the primary non-medical professionals who make medical decisions (unless they are one of the roughly 7% of Americans who are actually medical professionals). Competent adults have the final say on their own medical care, including consenting to or refusing care, choosing a treatment plan, and choosing to discontinue medical care, whether against medical advice or not. Healthcare proxies/agents (people named in an advance directive or durable power of attorney) and parents/legal guardians make these same decisions on behalf of patients.
How they Make Their Decisions: Patients and surrogates rely mainly on their clinicians, who are legally required to explain the risks, benefits, and alternatives of a treatment before obtaining informed consent. They also receive written materials such as discharge instructions, medication guides, and patient portal access to their own records, test results, and visit notes. Outside the clinic, they turn to reputable websites (MedlinePlus, Mayo Clinic, CDC), disease-specific advocacy organizations, support groups, second opinions, and increasingly AI chatbots and social media. Hospitals offer palliative care teams, patient advocates, and social workers to help families understand options during serious illness. Advance directives depend on the information the person had when writing them, often from conversations with their doctor, standardized forms such as POLST, and planning tools.
Often, medical decisions are not as clear cut as we might like, requiring the intervention of the legal system. Courts and judges sometimes have to step in when determining who the final decision-maker should be, such as in questions of guardianship, involuntary psychiatric commitment, court-ordered treatment, end-of-life disputes, and parental refusal of care on behalf of their children. The lawmakers themselves (state and federal Congressmembers) also make medical decisions ,casting votes about medical questions such as reproductive care, gender-affirming care, medical aid in dying, scope of practice, vaccine mandates, and controlled substances. Based on the laws they pass, medical decisions by medical professionals can be influenced heavily by issues such as risk of litigation when prescribing certain medications such as opioids, providing pregnancy-related care, or in the treatment of overdoses.
How they Make Their Decisions: Courts get medical information through evidence presented in each case: medical records obtained by subpoena, expert witness testimony from physicians on both sides, independent medical examinations, and reports from court-appointed evaluators or guardians ad litem. Judges decide which expert testimony is reliable enough to admit under established standards (such as Daubert). Courts may also read amicus briefs from medical societies. Legislatures rely on legislative staff, research agencies (at the federal level, the Congressional Research Service, Congressional Budget Office, and GAO), advisory commissions such as MedPAC and MACPAC, committee hearings with expert testimony, National Academies reports, state health departments, lobbyists, advocacy groups, and constituents. Malpractice attorneys and insurers use the plaintiff's medical records, retained expert reviewers, clinical practice guidelines that define the standard of care, and claims databases showing which errors lead to lawsuits. Prosecutors and police rely on medical examiner reports, prescription monitoring databases, DEA data, and expert witnesses.
In addition to lawmakers, regulatory agencies and federal/state programs heavily impact medical care decisions. The EPA, FDA, EMA and others ensure that medical devices, pharmaceuticals, and treatments meet requirements of safety and efficacy. CMS and state Medicaid programs make coverage determinations that impact healthcare access, and reimbursement rates shape what can be offered, where, and to whom. Public health departments issue quarantine orders, vaccination requirements, and outbreak responses. Correctional and immigration detention systems use administrators and contractors who make healthcare decisions for their residents.
How they Make Their Decisions: Agencies collect large amounts of data directly. CMS holds Medicare and Medicaid claims for tens of millions of people. The CDC runs national surveys and surveillance systems, including vital statistics, state disease reporting, the National Health Interview Survey, and NHANES. AHRQ maintains hospital-use and spending databases and funds systematic evidence reviews. The NIH funds most federal medical research, and the VA runs a large integrated health record system. The FDA reviews clinical trial data that manufacturers must submit, then tracks safety after approval through adverse event reports and its Sentinel system. The DEA and states use prescription drug monitoring program data. Health technology assessment bodies such as NICE combine published trials, cost-effectiveness models, manufacturer submissions, and patient input. Agencies also rely on expert advisory committees (FDA advisory panels, the CDC's ACIP, and the U.S. Preventive Services Task Force) and on public comments submitted through the Federal Register. Corrections and detention systems typically rely on contracted health vendors' reports, inspections, and accreditation standards.
Anyone with health insurance is well aware of the healthcare decisions made by third-party payers such as insurance companies. Through prior authorizations, formularies, network design, and claim denials, these entities effectively decide what care happens (by determining which claims they are willing to cover financially). Pharmacy benefits managers decide which drugs are covered, preferred, or require step therapy. Self-insured employers design their employees' benefits plans and chose what to include or exclude. Most, if not all of these companies contract utilization review firms to judge whether care is "medically necessary." While these entities do consult medical professionals, final decisions are often made by non-medical professionals and based on financial considerations in addition to health considerations.
How they Make Their Decisions: Insurers and PBMs base coverage decisions on clinical policies built from published studies, FDA labeling, professional society guidelines, and commercial criteria sets such as InterQual and MCG. Pharmacy and therapeutics (P&T) committees review drug evidence and pricing to build formularies, and some payers use independent assessments from groups like ICER. For individual claims, they review the medical records and documentation submitted by providers, and their own claims data shows utilization patterns and costs across members. Utilization review firms apply the same criteria sets, with nurse or physician reviewers for many decisions. Self-insured employers usually depend on benefits consultants, brokers, and third-party administrators, plus aggregated claims reports on their own workforce's health costs.
We have covered private equity and healthcare in this blog before, as their influence in healthcare continues to grow. Private equity firms buy physical practices, hospitals, nursing homes, and hospices and, in their efforts to turn a profit, shape staffing, scheduling, and service lines. Less directly, but also through financial pressures, venture capital determines medical care by deciding which health and biotech ideas get funded. The pharmaceutical and device companies decide what to research, which trials to run, how to price products, and when to change or discontinue products. There are other decision-makers influenced by the bottom line on the administrative side of medical care. Hospital and health system executives decide which services open or close, how many staff are hired, and what equipment is bought. Group purchasing organizations impact medical decisions by negotiating which supplies and devices hospitals actually stock and therefore have available for their patients. Exclusive licencing of innovations (that is, when only one brand has permission to sell the proprietary product) can mean that some patients do not have access to cutting-edge treatments because their healthcare provider chose a different brand. Retail and tech companies such as Amazon, CVS, and Walmart, increasingly run clinics, pharmacies, and telehealth services.
How they Make Their Decisions: Private equity and venture capital firms rely on due diligence: financial and billing records, market and reimbursement analyses, consultants, physician advisors, and expert networks that connect investors with clinicians for paid interviews. Their focus is typically on revenue, payer mix, and growth potential rather than clinical outcomes. Hospital executives use quality and safety dashboards, financial reports, CMS quality and payment data, community health needs assessments, input from medical staff leadership, and benchmarking services comparing them with peer hospitals. Pharmaceutical and device companies run their own research and clinical trials, license discoveries from universities, track the scientific literature, consult key opinion leaders and advisory boards of physicians, analyze market and claims data, and receive formal feedback from the FDA. Group purchasing organizations and retail health companies rely on clinical value-analysis committees, supplier data, and pricing analyses.
There are a number of lesser-known institutions and organizations that make or influence medical decisions. Hospitals have ethics committees that convene to handle difficult cases or set policies to help decision-making, including chaplains, lawyers, and community members. Organ allocation networks (UNOS/OPTN) set policies that determine who receives transplants. Accreditation bodies' standards shape hospital policies (Joint Commission and DNV). Some health systems are religiously affiliated, making some medical decisions based on ethical and religious directives. Schools and school boards set vaccination, medication administration, and sports participation policies, and employers may require fitness-for-duty exams (regulated by a variety of industry groups/government agencies), drug testing (regulated by state and local government), and workplace health rules (regulated by OSHA). Philanthropic foundations and donors influence medical care with their pocketbook, influencing research in their particular area by funding labs or initiatives, while patient advocacy groups bring public attention to medical conditions that could, in turn, influence funding and legislation. Media, including social media and influencers, shape demand for treatments, vaccine uptake, and overall trust in medicine, especially for younger patients.
With so many influences in medical decision-making, the central take-away is ensuring those decisions are based on high-quality, unbiased information. Patients and their medical teams should be aware of the many sources of information that may be influencing their decisions, and take the time to unpack those influences to determine what to trust. While some of these influences are out of our control as individuals, as a group, we have the ability to demand more transparency, both as informed voters and as informed consumers. The first step is that heightened awareness. We hope this post helped make that first step a little easier.