Guide
Understanding How Healthcare Decisions Are Made
This guide explains how healthcare providers, insurance companies, and patients contribute to healthcare decisions and how understanding their different roles can help people navigate care. It also provides practical questions patients can ask providers and insurance companies, along with prompts for considering their own goals, circumstances, and concerns.
Primary audience: Patients and families seeking to better understand how healthcare decisions are made.
Additional audiences: Healthcare professionals, caregivers, patient advocates, healthcare students, educators, and anyone interested in understanding the factors that influence healthcare decisions.
Topics Covered
- How healthcare providers may weigh clinical expertise, medical history, diagnostic information, risks and benefits, and evidence-based recommendations.
- How a patient's goals, preferences, and individual circumstances factor into provider recommendations.
- How insurance companies may consider covered benefits, medical necessity, documentation, prior authorization requirements, and coverage policies.
- What patients contribute, including daily routines, financial considerations, accessibility needs, and family, work, and community responsibilities.
- Questions patients can ask providers and insurance companies to better understand care and coverage decisions.
- How to consider whether a treatment plan is realistic and sustainable in everyday life.
Why This Resource Matters
Healthcare decisions can be difficult to understand because providers, insurance companies, and patients may each contribute different information, requirements, priorities, and perspectives. This guide helps people better understand those roles and provides questions that can support more informed conversations about care and coverage.
What's Inside
- What Influences Healthcare Providers' Decisions
- Clinical Expertise and Evidence-Based Recommendations
- Patient Goals, Preferences, and Individual Circumstances
- Questions to Ask Healthcare Providers
- What Influences Insurance Companies' Decisions
- Medical Necessity, Coverage Policies, and Prior Authorization
- Questions to Ask Insurance Companies
- The Patient's Role in Healthcare Decisions
- Daily Life, Financial, Accessibility, Family, Work, and Community Considerations
- Treatment Plan Practicality and Sustainability
Download the Resource
Formatted PDF
Includes graphics and layout.
Download PDF of Understanding How Healthcare Decisions Are Made (PDF, opens in a new tab)Additional Resources from Other Organizations
- AHRQ – About Shared Decision Making (opens in a new tab)
Describes shared decision making as a collaborative process where clinicians and patients (and often family or caregivers) use evidence, clinical expertise, and the patient's values, goals, preferences, and circumstances to make healthcare decisions together.
- HealthCare.gov – Health Insurance Glossary (opens in a new tab)
Defines common health insurance terms such as medical necessity, prior authorization, deductible, coinsurance, coverage policies, and explanation of benefits in plain language, supporting understanding of insurance-related factors in healthcare decisions.
- NIH MedlinePlus – Lab Tests (opens in a new tab)
Explains common laboratory tests and what they measure, helping readers understand one of the key clinical inputs—diagnostic testing—that influences healthcare decisions alongside symptoms, medical history, and physical examinations.
Continue Learning
Keep exploring with another resource from the Center for Person-Centered Care.
Guide
When Health Insurance Says No Or Makes You Wait
Learn what to ask, what to document, and what steps may help when health insurance delays or denies care or coverage.
Explore Resource – When Health Insurance Says No Or Makes You WaitUnderstand how healthcare decisions are made to ask better questions and make more informed choices that reflect your goals, priorities, and everyday life.
The Health Guides, Visual Snapshots, and Clinical Practice Resources were reviewed by a physician for clinical accuracy and by other reviewers to improve readability, clarity, and ease of understanding.
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