Proactive Care Is Not a Luxury Tier

Somewhere along the way, we started treating proactive healthcare like a luxury.

More time with your physician? Concierge.

A physician who actually knows you? Premium.

Regular follow-up between visits? Executive medicine.

Someone looking at your health before something goes wrong? An upgrade.

I think we've got this backwards.

Proactive care isn't a luxury because it is unnecessary.

It is different because it requires a different model of healthcare.

And if we want to understand why that model is becoming necessary, we need to talk about something physicians don't always talk about openly:

Who is healthcare actually being designed for?

Because increasingly, it doesn't feel like the system is designed around the patient.

It feels like it is designed around the payer.

The Hidden Cost of Insurance-Based Healthcare

Most people think about the cost of healthcare in terms of what they pay.

The premium.

The deductible.

The copay.

The bill.

But there is another cost that is much less visible:

the cost of physician time.

And the way that time is compensated can be profoundly disconnected from the amount of work actually required to care for a patient.

A physician may spend 15 or 20 minutes with a patient and receive compensation based largely on that billable encounter.

But the work doesn't end when the patient walks out.

There is reviewing records.

Ordering and interpreting tests.

Communicating results.

Calling specialists.

Writing notes.

Responding to messages.

Completing forms.

Calling insurers.

Submitting prior authorizations.

Appealing denials.

Documenting why a treatment is medically necessary.

And sometimes spending significant amounts of time arguing with another physician at an insurance company about a decision that directly affects the patient's care.

Much of this work is invisible to the patient.

But it is very real.

And increasingly, it is consuming the physician's time.

The Work Patients Never See

Imagine a patient comes into clinic.

You spend 30 minutes with them.

You listen carefully.

You review their history.

You examine them.

You develop a plan.

You explain it.

They leave.

From the patient's perspective, the visit is over.

From the physician's perspective, the work may have just begun.

Suppose you determine that a medication, imaging study, or treatment is medically appropriate.

You submit the order.

Then you get a message:

Prior authorization required.

What is prior authorization?

In simple terms, it means the insurer requires the physician to obtain approval before it will agree to cover a particular medication, test, procedure, or treatment.

Sometimes the request is approved.

Sometimes it is denied.

Sometimes the insurer asks for additional documentation.

Sometimes it requires the patient to try another treatment first.

Sometimes the physician has to appeal.

And sometimes the physician has to spend time explaining to an insurance reviewer why the treatment they prescribed is appropriate for the patient sitting in front of them.

None of that is the patient's fault.

And much of it isn't really clinical medicine.

But the physician still has to do it.

A Hospital Example: The Peer-to-Peer

I saw this repeatedly as a hospitalist.

Imagine you're caring for a patient who has been hospitalized for several days.

They are medically ready to leave the hospital and transition to a rehabilitation facility or another level of care.

The facility is appropriate.

The patient needs continued support.

The clinical team agrees.

But the insurance company doesn't approve the next level of care.

Now you may be asked to participate in a peer-to-peer review.

A physician working for the insurer gets on the phone with the treating physician.

You discuss the patient's condition.

You explain why the patient still requires a particular level of care.

You review the clinical facts.

You advocate for your patient's needs.

Sometimes the decision changes.

Sometimes it doesn't.

But think about what just happened.

You were trained to take care of sick patients.

And instead of spending those minutes at the bedside, you are now spending them on the phone trying to convince another physician—who has never examined your patient—that the care you believe is medically necessary should be covered.

There are situations where utilization review is appropriate. Healthcare resources are finite, and responsible stewardship matters.

But when administrative processes become so extensive that they pull physicians away from direct patient care, we have to ask whether the system has lost sight of its purpose.

The Clinic Version Can Be Just as Frustrating

Now take the same problem into outpatient medicine.

A patient needs a particular medication.

You prescribe it.

The insurer says:

"Not covered without prior authorization."

So someone has to submit additional documentation.

Maybe you need to explain the diagnosis.

Maybe you need to document previous treatments.

Maybe you need to demonstrate that the patient has failed another medication.

Maybe you need to complete a multi-page form.

Maybe the insurer denies it.

Now you appeal.

Perhaps the appeal requires more documentation.

Perhaps there is another review.

Perhaps eventually you have to participate in a peer-to-peer conversation.

And all of this happens before the patient ever receives the treatment you originally prescribed.

Again, sometimes these processes protect patients from unnecessary or inappropriate care.

But the problem is what happens when the administrative machinery becomes so large that the physician's scarce time is increasingly spent serving the requirements of the payer rather than the needs of the patient.

That distinction matters.

When Physician Time Becomes Insurance Time

This is one of the things that changed how I thought about healthcare.

A physician's day isn't simply divided into:

Patient care + everything else.

The "everything else" can become enormous.

And much of it exists because the healthcare system has created a complex negotiation between the physician, the patient, and the payer.

The patient sees the physician.

The physician makes a clinical decision.

The insurer determines whether that decision meets its coverage criteria.

And the physician is increasingly responsible for proving it.

That's a very different relationship from:

Patient → Physician → Care.

It becomes:

Patient → Physician → Documentation → Payer → Authorization → Appeal → Care.

And every additional step consumes time.

This Is Part of Why Physicians Burn Out

When we talk about physician burnout, the conversation often focuses on workload.

But workload isn't simply the number of patients you see.

It's the nature of the work.

There is a profound difference between spending an additional hour thinking about patients and spending an additional hour fighting an administrative process.

One is medicine.

The other may be necessary to practice medicine within the system—but it isn't why most physicians went to medical school.

According to the American Medical Association, 41.9% of physicians reported at least one symptom of burnout in 2025.

That's an improvement from the pandemic-era peak, but it still means roughly two out of every five physicians are experiencing symptoms of burnout.

And physician burnout isn't just a workforce problem.

A large systematic review and meta-analysis involving more than 42,000 physicians found that burnout was associated with nearly twice the odds of patient safety incidents, along with poorer quality of care and lower patient satisfaction.

That should force us to think differently about burnout.

Because perhaps the answer isn't simply teaching physicians to become more resilient.

Perhaps we should also ask:

What are we asking physicians to be resilient against?

Physicians Didn't Go to Medical School to Become Insurance Negotiators

This is not an argument against insurance.

Insurance plays an essential role in healthcare.

It protects people from catastrophic financial risk.

It helps make care accessible.

It allows people to receive treatments and services they could not otherwise afford.

And utilization management exists for legitimate reasons.

The issue is balance.

At what point does administrative oversight become administrative overload?

At what point does the process intended to control costs start consuming the very resource healthcare is already short on:

physician time?

And what happens when the physician's most valuable resource—clinical judgment—is increasingly spent navigating a payer's rules?

That's the part of the system I believe deserves much more attention.

The Economics Create Another Problem

There is another uncomfortable reality.

In a traditional insurance-based model, physicians are generally compensated according to a defined set of reimbursable services.

The physician's time, however, is much larger than the time that appears on the claim.

A 20-minute appointment can require another 10, 20, or 30 minutes of work around it.

But that additional time may not be separately compensated—or may be compensated at a fraction of what the physician's clinical time is worth.

Now multiply that across dozens of patients.

The economics start pushing physicians toward volume.

See more patients.

Move faster.

Reduce the time between appointments.

Delegate what you can.

Document everything.

Keep the schedule full.

And when the day ends, finish the messages, charts, authorizations, forms, and calls.

It's not hard to understand why physicians become exhausted.

The system isn't necessarily asking them to do less.

It's asking them to do more—often without creating more time to do it.

This Is Why Direct Care Exists

This is the part that matters to me personally.

I built Aure Health as a direct-care practice because I wanted to create a different economic relationship between the patient and the physician.

Not because insurance is inherently bad.

Not because I believe everyone should pay for their healthcare out of pocket.

And not because proactive care should be reserved for wealthy people.

I chose direct care because the kind of medicine I want to practice requires time.

Real time.

Time to understand the patient.

Time to review their history.

Time to think.

Time to communicate.

Time to follow up.

Time to be accessible.

Time to focus on prevention instead of simply reacting to problems.

And I didn't want that time to be constrained by how many patients I could fit into a schedule or by whether an insurer would reimburse every interaction required to care for them properly.

The Membership Isn't Paying for "Luxury"

When someone joins Aure Health, they're not simply paying for a nicer waiting room or an extra annual physical.

They're paying for a different relationship with their physician.

A smaller patient panel.

More time.

Direct communication.

Continuity.

Proactive follow-up.

Long-term planning.

And a physician who can spend more of their professional time thinking about the patient rather than the payer.

That's an important distinction.

Because the direct-care model doesn't eliminate the value of physician time.

It acknowledges it.

Physician time is the product.

And if we want physicians to have more of it to give to patients, we have to create an economic model that supports it.

I Don't Want to Hide the Cost

I also don't believe in pretending this model is free.

It isn't.

Physician time costs money.

A smaller patient panel costs money.

Accessibility costs money.

Longer visits cost money.

Continuous engagement costs money.

The infrastructure to support that relationship costs money.

There is a tendency in healthcare to hide those economics behind insurance.

But I think patients deserve transparency.

The question isn't whether high-touch physician care costs something.

Of course it does.

The question is:

What are you paying for?

Are you paying for more healthcare?

Or are you paying for more time, continuity, access, and attention from a physician?

At Aure Health, it's the latter.

Proactive Care Requires Time

And this brings me back to the original point.

Proactive care is not a luxury because it is unnecessary.

It can feel like a luxury because our current healthcare infrastructure has made time with a physician scarce.

If you want to prevent disease, you need time to understand risk.

If you want to improve metabolic health, you need time to understand behavior.

If you want to change lifestyle, you need time to follow up.

If you want to improve longevity, you need time to think beyond the next appointment.

If you want a physician to know you, they need time to actually know you.

And time is precisely what the traditional healthcare model has been progressively compressing.

The Goal Isn't to Escape the Healthcare System

Aure Health isn't designed to replace hospitals.

It isn't designed to replace specialists.

It isn't designed to replace emergency medicine.

And it certainly isn't designed to pretend that insurance isn't necessary.

The traditional healthcare system is essential for many parts of medicine.

What I believe is missing is another layer.

A place where patients can build a long-term relationship with a physician before they become acutely ill.

A place where prevention has room to breathe.

A place where technology supports the relationship rather than adding another layer of complexity.

A place where the physician's time is directed primarily toward the patient.

We Need to Stop Asking Physicians to Do More With Less Time

Perhaps the healthcare conversation needs to change.

Instead of constantly asking:

How can we make physicians more efficient?

Maybe we should sometimes ask:

How can we give physicians more time to be physicians?

Instead of asking:

How can we squeeze more patients into the schedule?

Maybe we should ask:

What happens when a physician actually has enough time to know their patients?

Instead of asking:

How do we manage disease more efficiently?

Maybe we should ask:

How do we prevent more disease in the first place?

These are not small changes.

They're different assumptions about what healthcare is supposed to accomplish.

Proactive Care Isn't a Luxury Tier

I don't believe everyone needs direct care.

I don't believe everyone needs a concierge-style relationship with their physician.

And I don't believe the traditional healthcare system is going away.

But I do believe there are people who want something different.

People who want to take their health seriously before a crisis forces them to.

People who value prevention.

People who want continuity.

People who want a physician who knows them.

People who don't want their healthcare relationship to begin and end with an insurance claim.

For those people, direct care can create something that the traditional model often struggles to provide:

time.

And time is not a luxury when it comes to health.

Time is how you notice things early.

Time is how you understand the whole person.

Time is how you build trust.

Time is how you change behavior.

Time is how you prevent problems before they become crises.

And time is how physicians get back to doing the work they entered medicine to do.

Proactive care isn't a luxury tier.

It's a different way of thinking about healthcare.

And sometimes, changing healthcare doesn't mean asking the existing system to do more.

It means building a model that allows physicians to spend more of their time doing what patients actually need them to do.