When rowers are aligned — matching their timing, rhythm, and pressure — the boat holds a steady line. Coordinated strokes are essential whether tracking straight down the course or deliberately turning. When rowers fall out of sync, the shell drifts and energy goes into correction rather than progress.
When plans and clinicians pull in different directions — one toward cost pressures, the other toward clinical judgment — the boat drifts and energy goes into constant course correction. But when both sides row together, the work stabilizes and the path ahead becomes clear. Shared decision making between clinicians and health and drug plans is one of the most effective ways to keep the boat on course.
Kaiser’s model built around clinician authority
Kaiser Permanente’s approach to shared decision making traces directly back to its mid-century origins. In 1955, leaders from Kaiser Foundation Health Plan (KFHP) and Hospitals met with physician leaders at the Tahoe Conference to resolve tensions around control and the long-term direction of their emerging model. The result was a clear governance compact: Kaiser Foundation Health Plan and Hospitals would manage capital and infrastructure, while the Permanente Medical Groups (PMGs) would govern the practice of medicine. That division — operational authority on one side, clinical authority on the other — became Kaiser’s structural backbone.
Over time, the PMGs evolved into large, self-governed, multispecialty groups whose leaders are practicing physicians. Service-line chiefs, clinical guideline committees, and decision-making bodies are chaired by Permanente clinicians rather than administrators. This culture endures: Physicians design the clinical rules, and the health plan operationalizes them. This dynamic is most visible in Kaiser’s internal guideline ecosystem, where the PMGs work with the Care Management Institute, which is co-sponsored by the PMGs and KFHP, to develop evidence-based clinical practice guidelines. These guidelines inform PMG-approved care pathways, decision-support tools, drug utilization criteria, and coverage policies.
Even in Medicare Advantage, where CMS requires uniform benefits across a plan’s service area, Kaiser layers clinician consensus on top of regulatory mandates. Regional committees inform a national formulary process, and any regional differences are reconciled through a physician-led, consensus-driven national review. The result is a structure in which clinicians co-create, approve, and maintain the rules that guide care — rules that the plan then aligns with, rather than imposes upon them.
How other health and drug plans involve clinicians
While no other organization replicates Kaiser’s structure, most health and drug plans have established forums where clinicians influence key decisions — particularly through committees responsible for formularies, medical policies, and technology assessments. These committees typically include voting physicians from diverse specialties, network clinicians, plan medical directors, and invited experts for topic-specific deliberations.
Across commercial, Medicaid, and Medicare Advantage products, these committees serve as the central mechanism for embedding clinical judgment into plan decision making. Physicians review evidence for new therapies, evaluate coverage proposals, weigh real-world practice patterns, and deliberate on criteria that affect access. Specialists are routinely invited to present clinical context, explain diagnostic and treatment workflows, or identify unintended consequences of proposed rules.
Though the structures differ from plan to plan, the common thread is that clinician participation is built into the decision-making process. These committees serve as the primary venues where clinical and administrative perspectives meet. While plans vary in how broadly they involve their networks, the underlying idea is consistent: Decisions are more workable when they reflect real clinical practice rather than abstract policy preferences.
Why shared decision making reduces friction
Shared decision making reduces friction because it aligns clinical practice and policies. Across clinical governance studies and the organizational behavior literature, four patterns consistently explain why shared approaches to decision making lead to soother implementation and fewer disputes.
First, people are more likely to follow rules they help create. Research shows that when workers participate in shaping standards or policies — even if they do not control the final decision — their compliance rises and resistance falls. This pattern holds in settings from manufacturing to professional services, and it has been repeatedly observed in the governance of clinical guidelines, coverage policies, and formularies. When clinicians perceive a decision as legitimate because their peers shaped it or influenced its formation, they are more inclined to support it than something they feel is imposed on them.
Second, early involvement matters more than later consultation. Bringing subject-matter experts in after a policy is drafted rarely changes outcomes and often intensifies frustration. Engaging clinicians at the beginning — before criteria are written or rules are set — produces clearer alignment, fewer downstream challenges, and fewer appeals. This parallels findings from other sectors: Early stakeholder participation tends to improve policy acceptance, whereas late engagement feels performative. When issues are surfaced early, policies that result tend to be more realistic, reducing downstream disputes or the need for revisions.
Third, diverse representation improves decisions. Research across industries shows that governance bodies with diverse expertise reach more stable and widely supported decisions. In the context of health and drug plans, the involvement of a wider array of clinicians — different specialties, practice settings, and patient populations — reduces blind spots, improves the fit between policy and practice, and minimizes the mismatch that often generates conflict. This results in policies that are more closely with the realities of varied clinical environments.
Fourth, decisions gain legitimacy when their underlying reasoning is clear and grounded in recognizable clinical logic. Clinicians are more likely to trust and support new policies when they understand the rationale for decisions, see their colleagues involved, and observe that the process reflects real-world considerations. This legitimacy reduces the friction that typically arises when coverage criteria or utilization management rules feel disconnected from clinical reality.
What health and drug plans can do now
If health and drug plans want to reduce friction with clinicians, they do not need to overhaul their structures. They already have the committees and forums where shared decision making can thrive. The opportunity lies in strengthening these mechanisms rather than inventing new ones.
First, plans should expand the breadth of clinician involvement in existing committees, especially in areas where practice patterns vary significantly. Broader representation ensures that coverage rules and formularies better reflect on-the-ground realities across specialties and settings.
Second, plans should involve clinicians earlier in the policymaking process. This includes briefing before evidence reviews begin, early-stage conversations about where variation in practice and evidence is creating uncertainty, and clinician input on how a policy problem is framed. Early engagement fosters clarity and surfaces operational issues before policies are drafted.
Third, plans should reassess the balance of power in their decision-making structures. This may mean increasing voting clinician members, adjusting voting thresholds, or ensuring that specialty clinicians hold meaningful influence in decisions affecting their practice areas.
Fourth, plans should strengthen the legitimacy of new policies by providing clear, concise rationales. This includes summarizing the evidence reviewed, explaining how competing considerations were weighed, a showing where clinician input shaped the final criteria. Making the reasoning visible helps clinicians understand how a decision was reached.
Together, these steps reinforce the principle that clinicians should play a central role in shaping the rules they later must follow. This alignment not only reduces operational friction but also leads to more practical, more accepted, and more sustainable policies.
Shared decision making is not a luxury — it is a necessity. Plans already rely on clinicians to guide formulary and medical policy decisions. Strengthening that collaboration, engaging clinicians earlier, and widening the circle of participants are steps plans can act on now.
When the people shaping coverage and access move with a shared sense of direction, the work becomes steadier and more predictable for everyone involved. Health and drug plans can help set that direction now by engaging clinicians early and meaningfully in the decisions that guide care — one stroke at a time.
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