Questions That Matter
Understanding How Healthcare Decisions Are Made
Health Guide No. 3, Published August 2026
Learn how healthcare providers, insurance companies, and patients each shape healthcare decisions, with practical questions you can ask about your care and coverage.
Primary audience: Patients and families seeking to better understand how healthcare decisions are made.
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Understanding How Healthcare Decisions Are Made
Better healthcare depends on informed questions, engaged communities, and decisions that reflect people's needs.
This guide explains how healthcare providers, insurance companies, and patients contribute to healthcare decisions and how understanding their roles can help you navigate your care.
What Influences Healthcare Providers' Decisions
Providers may factor in:
- Their training, professional expertise, and scope of practice.
- Input from colleagues and other specialists.
- Your medical history, symptoms, physical examination, and diagnostic test results.
- Several possible explanations for your symptoms before reaching a diagnosis (or differential diagnosis).
- The potential benefits and risks of different treatment options.
- Your goals, preferences, and personal circumstances.
- Evidence-based recommendations developed by federal agencies, expert advisory bodies, and professional organizations for topics such as vaccinations, mammograms, colon cancer screening, and other preventive healthcare services.
- How evidence-based recommendations may differ based on your individual circumstances.
Questions for Providers
Consider the questions that may be helpful to your situation.
- What other possibilities were considered?
- What evidence or clinical guidelines support this recommendation?
- What are the benefits and risks of my options?
- How do my goals or circumstances affect this recommendation?
- Here is my understanding of next steps. Is this correct?
- Do my individual circumstances change which evidence-based recommendations are appropriate for me?
What Influences Insurance Companies' Decisions
Insurance companies may consider:
- Your plan's covered benefits.
- Medical necessity.
- Supporting medical documentation.
- Prior authorization requirements.
- Coverage policies.
- Federal and state laws, regulations, and guidance.
Questions for Insurance Companies
Consider the questions that may be helpful to your situation.
- Is this service covered under my plan?
- How is medical necessity determined?
- What documentation is required?
- Can you show me where my policy explains the basis for this decision?
- What additional information could change this decision?
- What are my appeal options if coverage is denied?
Your Important Role in Healthcare Decisions
You are best positioned to contribute:
- Your goals and preferences.
- Your daily routines and lived experiences.
- Financial considerations.
- Transportation or accessibility challenges.
- Family and caregiving responsibilities.
- Work, school, or community obligations.
- Insight into whether a treatment plan is practical and sustainable for your life.
- What motivates you to follow a treatment plan and what barriers may make it difficult.
- Your understanding of the treatment plan and any questions or concerns you have.
Ask yourself:
- Have I shared what matters most to me?
- Have I discussed any challenges that could affect my treatment plan?
- Is this recommendation realistic for my daily life?
- Do I understand my options?
- Do I understand the treatment plan?
- What questions do I still have?
Note: This guide reflects the U.S. healthcare system and is a living document that continues to evolve.
Prepared by Cynthia Overton, PhD
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.
Understand 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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