Response from Dr. Glinka Przybysz

Restrictions to medical care have long been documented within the medical literature. Prior authorization requirements have been shown to significantly delay patient care, including access to imaging, interventional procedures, and medically necessary spine surgery. The literature consistently demonstrates that current insurance practices create barriers that are not tied to clinical indicators of surgical necessity and result in a “mismatch between treatments found safe and effective and those routinely covered.”1,2

Insurance prior authorization requirements clearly delay care and create inequitable access, with the processes delaying spine surgery by an average of 11-14 days, even when ultimately approved.1,3 For patients requiring appeals, delays extend to nearly a month.4 These delays occur regardless of clinical severity; presence of myelopathy, cord compression, or neurologic deficits does not predict prior authorization requirements or approval.1

These barriers to care are occurring in the context of a constantly changing insurance landscape. Medicare Advantage plans now cover more than half of Medicare beneficiaries—over 36 million patients in 2026.5 These managed plans are well-known for utilization management tools such as prior authorization and restricted networks, which can create substantial barriers to specialty care, including access to interventional spine physicians and spine surgeons.6 Practicing spine specialists need not be current on the published literature to know this is true, as it is their lived professional experience. Physicians routinely spend significant time performing nonbillable administrative work to obtain approval to provide standard-of-care spine services.

From the insurers’ perspective, these processes are intended to limit unnecessary diagnostic tests and procedures and protect patients from low-value care. However, such decisions are often made without the same level of specialty expertise as the treating physician, raising concerns about the appropriateness of these determinations.7

While the literature clearly documents the problem, the ethical implications of how physicians should respond to these barriers remain largely unexplored. Within this context, an important question emerges: Is it ethically permissible for physicians to decline participation in insurance plans that create substantial barriers to appropriate care? Professional societies have largely avoided taking explicit positions on whether physicians should or should not participate in particular insurance networks. However, the broader medical ethics literature provides relevant principles and examples that can help frame the issue.

One relevant precedent exists in psychiatry. The medical literature shows that psychiatrists consistently decline participation in private insurance plans at substantially higher rates than other medical specialists—nearly half do not accept private insurance. This pattern is generally attributed to a combination of low reimbursement relative to the time required for care, administrative burden, and workforce shortages that create high demand for services.8,9 Although this practice is well documented, the ethical implications should be considered here. However, no major professional societies have explicitly endorsed or condemned this practice, illustrating that physicians’ decisions about insurance participation are historically treated as individualized professional choices rather than strictly regulated by ethical obligations.

Evaluating this question through the traditional principles of medical ethics highlights the tensions involved. Beneficence, the obligation to act in the patient’s best interest, may support withdrawing from systems that systematically obstruct timely and effective treatment. A spine specialist may reasonably conclude that participation in a plan that routinely delays imaging or procedures prevents them from providing optimal care. Nonmaleficence, the duty to avoid harm, raises similar concerns. Administrative barriers can lead to prolonged pain, delayed diagnosis, and potential disease progression. If participation in certain plans requires physicians to comply with processes that cause predictable delays, opting out may be ethically defensible. At the same time, both principles also generate an important counterargument: if physicians leave restrictive networks, patients who rely on those plans may lose access to specialty care altogether.

Other ethical principles complicate the analysis further. Respect for patient autonomy requires that patients have meaningful opportunities to participate in decisions about their spine care. Yet insurance restrictions can severely limit available options, effectively narrowing the scope of patient choice. Conversely, if specialists decline participation in certain insurance plans, patients with those plans may have even fewer options available to them. Justice, which emphasizes fairness and equitable access to care, raises perhaps the most significant concern. Patients with the most restrictive insurance plans are often those with fewer financial resources. If increasing numbers of spine specialists leave these networks, disparities in access to specialized spine care could worsen.

The broader medical literature provides additional perspective. The American College of Physicians (ACP) has emphasized that physicians must structure their professional relationships in ways that support their obligations to patients, underscoring the ethical principles of justice, and nonmaleficence.10 The ACP’s 2025 position paper on managed care specifically notes that prior authorization requirements and narrow networks “often restrict access to necessary care” and calls for policies that ensure patients can promptly access high-value, medically necessary treatments.11 Similarly, several other professional organizations emphasize physicians’ duties of loyalty and advocacy for their patients when interacting with health plans.12

Other professional organizations reinforce this responsibility of advocacy. The American Academy of Neurology states that physicians have a professional obligation to help patients gain and maintain access to needed treatment and to advocate for improvements in the health care system when barriers arise. The American Academy of Physical Medicine and Rehabilitation, American Medical Association and American College of Obstetricians & Gynecologists likewise identify physician advocacy, including advocating for “availability and access,” as an essential component of addressing systemic barriers to care.13-15

At the end of the day, the literature highlights a persistent ethical tension. Physicians have a duty to advocate for their patients and to work toward systemic changes that reduce barriers to care. Yet there is little guidance on whether declining participation in certain insurance plans could be considered an ethically permissible form of advocacy. While NASS has made notable strides in advocacy work in many other areas15–17, perhaps this is something we can tackle in the coming years.