This editorial was submitted by TMA's 2025-2026 President, John McCarley, MD, of Chattanooga, Tenn. 

As a physician leader, I feel an obligation to respond to what has been said about healthcare providers by executives within the health insurance industry via recently published opinion pieces.

I strongly disagree with the opinion published in the Tennessean February 26, 2026 by Scott Pierce, COO of Blue Cross Blue Shield of Tennessee regarding TMA-supported legislation, he states would increase premium costs if passed.  Consider this: Insurance premiums increase nearly every year. For most Americans without employer coverage, good quality, and widely-accepted private health insurance is simply not affordable.  Employee health care insurance cost is one of the very largest expenses any business owner pays. This is not a phenomenon driven by TMA legislation, but we do hope to curb costs through the legislation we are now proposing.

It could be argued that the one healthcare entity least interested in continuity of care is the private healthcare insurance industry and it makes little difference if it is a for-profit or not-for-profit company as the games we are forced to play as providers and patients are pretty much the same.   Honest and hard-working Tennessee families have continually faced rising premiums, higher deductibles, and insurance networks that shrink every year forcing them often to find new doctors. 

How do I know this? Patients complain to me about these issues every day I practice medicine.   

Every year, well-meaning physicians and sick patients are forced anew to navigate additional prior authorization requests, poorly explained claim denials, altered provider network panels and reimbursement changes. These disrupt medical practices’ long-term viability and disrupt patient care. Annually revised drug coverage rules make little to no sense to anyone involved. 

Physicians waste a large portion of time, manpower, and payroll not on patient care, but navigating a fragmented healthcare landscape. Patients are not spared these time-consuming tasks. My own wife who has multiple chronic conditions deals with it all the time. I know firsthand how awful it is for patients and their families.  

My fellow Tennesseans, you deserve transparency on these topics. But I too don’t understand all of it.  Healthcare spending in Tennessee continues to increase. Rural hospitals keep closing. Longstanding and highly regarded independent medical practices are driven, intentionally or not, toward large health systems run by hospitals or sometimes owned and run by the insurers themselves, sometimes towards private equity firms who know next to nothing about public health. Sometimes practices are driven out of the state altogether. 

The TMA is proposing legislation to address the following issues:

1. Payment transparency and predictability. Traditionally, insurance pays the medical practice for services rendered. The practice pays its staff (both medical and administrative) wages and benefits, pays insurance, pays rent, pays utilities, etc. Arbitrary and unannounced payment reduction by an insurance company for services rendered to a complicated patient is a violation of trust for the patient client. Several private insurance companies, including BCBS, started doing this to provider practices out of nowhere this past spring/summer. There was no warning and no time to plan for it. Suddenly medical practices could not afford to pay their bills. Discussions between physician leadership and insurance executives were nearly pointless. None of these companies were willing to consider at least pausing what they were doing. Please understand, arbitrary reduction of payment inevitably pushes the provider towards more appointments per unit of time and potentially lowers quality of services. Within medical care such a model is completely unfair and dangerous to patients.
2. Timely access to necessary medical care. There are certain types of procedures and medications which nearly always get approved after a prior approval request or initial denial. It is ridiculous for patients with steadily worsening medical conditions, and their providers, to repeatedly waste their time trying to persuade the insurance company to do the correct thing. The amount of manpower insurance companies expend disapproving good medical care adds to healthcare costs. You see, they have to pay their people too. Your rising healthcare premium and also your increased deductible pays that additional cost for them. Finally, approval is approval. It should be sustained. It should not face reevaluation 6 months later, particularly if the chosen treatment is effective or if 6 months is too early to know. The insurance company has said the doctor was right. Let it be.
3. Fair and sustainable provider payment structures. Vertically integrated medical systems are a phenomenon wherein large private companies, perhaps an insurance company, owns a pharmacy company, owns the pharmacy benefit management structure, and sometimes owns medical practices. It has been recently proven these structures raise costs because they act as a monopoly. They dictate what you pay in nearly all aspects. Furthermore, healthcare workers of all types working within such a structure have little independent decision-making capacity and are badly overworked by a volume (not quality) based model. The doctor-patient relationship becomes a shell of itself in such a model. Protected payment models for community based medical practices helps to ensure that they are not forced to migrate into a vertically integrated system. This is better for all communities regardless of size. PS – No, I do not believe CVS pharmacies will close because of the pharmacists’ proposed legislation. If they do, you’ll most certainly, in a capitalist system, be provided with something better.  So please ignore the signs they have posted in their stores.

Finally, a word regarding the Opinion piece by Dr J. B. Sobel titled “Artificial Intelligence (AI) in Medical Billing Matters for Healthcare Costs.”  While I do not personally know of any clinicians who are using AI to choose their diagnostic codes and billing practices, I do know of several who use an AI scribe program to generate notes. At the end of the encounter, the clinician is solely responsible for the content of their signed note. We are expected to bill only for the complexity of the patient and the medical decision making including the thinking expended toward new issues and the chronic diseases of the patient. If technology assists us in writing a note better reflecting what actually happened and includes consideration of old and new medical elements (including outside data), it becomes a documented encounter on level with medical complexity. The charge will (and must) reflect this. Complexity isn’t just what was done; rather, what all was considered. Sometimes you treat one thing with intent of not worsening something else; hence two codes, not one. AI in its present form is not robust enough by itself to accomplish this in a safe manner.  

Tennesseans deserve a health insurance market which promotes both affordability and access.  This legislative session, the Tennessee Medical Association intends to work towards restoring that balance.