The recent advisory by a local insurance company requesting that doctors obtain prior authorization to order a laboratory test, C-reactive protein (CRP) assay, has stirred serious concern among clinicians. While the insurer’s motive is understandable in that CRP tests can be relatively expensive, many physicians view the measure as an intrusion on their professional autonomy, clinical judgement, and duty to deliver evidence-based care.
At the core of this dispute is the tension between two legitimate but sometimes conflicting objectives:
1. Doctors’ duty to the patient
Physicians assess clinical presentation, order investigations (blood tests, imaging, etc.), and interpret results in light of patient history and examination — in order to reach an accurate diagnosis and guide therapy. For example, in emergency or acute care settings, CRP (often alongside white cell count, renal profile, etc.) is frequently used to assess inflammation or infection and guide clinical decisions.
2. Need for cost-containment and rational utilization
Laboratory and radiological testing, when overused or repeated unnecessarily, can lead to wasted resources, increased healthcare costs, and even potential harm from overdiagnosis or cascading unnecessary investigations.
In Kenya’s current economic climate — where many patients depend on insurance cover to afford care — the insurer’s concern about cost is not unfounded. However, when insurers dictate what tests “must” or “must not” be done, they risk undermining the doctor-patient relationship and the doctor’s clinical autonomy. On the other hand, unconstrained overuse may contribute to rising premiums, inefficiencies, and long-term unsustainability of health insurance.
Hence, a balance must be found: one that respects doctors’ clinical independence, safeguards patients’ interests, promotes evidence-based care, and ensures responsible resource utilization.
Why Both Sides Have Valid Concerns: The Trust Deficit
From the Doctors’ Perspective
– Many doctors believe the insurer’s requirement amounts to undue interference: limiting their ability to order investigations they deem clinically necessary. This undermines their autonomy and the ethical principle that the doctor should decide on necessary care based on clinical judgement.
– There is also a history (in Kenya) of some insurers denying payment for doctor services according to fees set out by professional guidelines (e.g. by the Kenya Medical Practitioners and Dentists Council), which fuels scepticism about insurance motives.
– Some doctors suggest that, rather than dictating to doctors, insurers should instead inform policy-holders (patients) about what tests their premium covers — allowing patients and doctors to make informed decisions together.
From the Insurer’s Perspective (and Broader System Concerns)
– Insurance firms face pressure to keep premiums affordable and to control costs, especially in a context where diagnostic services may be overused or repeated unnecessarily. Unregulated test ordering can lead to escalation of claims.
– There is global evidence that overuse and repetition of laboratory tests — even “basic” but expensive tests — contribute significantly to waste.
– In some systems, unrestricted test ordering under third-party payment (insurance) becomes a driver of overutilization, since neither patient nor physician may feel the cost directly.
This mutual distrust — doctors fearing economic motives; insurers fearing overutilization — erodes the foundation of collaboration needed for effective care delivery. Without restoration of trust, patients may end up as the losers: either denied necessary tests or exposed to unnecessary ones.
International Best Practices: What Other Countries are Doing
Many countries have grappled with similar tensions. Some of the best-practice approaches include:
Choosing Wisely
This is a clinician-led, evidence-based campaign aimed at identifying and reducing “low-value” tests, treatments, and procedures — those unlikely to benefit the patient, may cause harm, or create unnecessary costs. Choosing Wisely does not adopt a cost-cutting or rationing stance per se; instead it emphasizes clinician–patient dialogue. Physicians and patients together discuss whether a given test or procedure is truly necessary.
Stewardship programs
Many health systems are developing or deploying diagnostic stewardship programs — structured frameworks to guide appropriate testing. These involve a mix of clinical guidelines, decision-support tools, utilization review, and laboratory test algorithms — encouraging “right test, right patient, right time.”
Lab-on-demand
Institutions sometimes adopt “laboratory-on-demand” or “test utilization management” strategies: requiring that every test request be linked to a clinical indication, discouraging routine or reflexive ordering of expensive tests, avoiding unnecessary repetition, and setting minimal intervals between repeat testing.
These globally accepted initiatives share several principles: medical-indication based test ordering; shared decision-making with patients; stewardship to prevent overuse; and respect for professional autonomy when justified by clinical need.
What Should Happen in Kenya: A Balanced Path Forward
Given the local context — economic constraints, dependence on insurance, but also widespread professional commitment among doctors to deliver quality care — I propose the following balanced approach. This is also what I believe the Kenya Medical Association (KMA) should consider advocating for.
1. Establish a Kenyan “Choosing Wisely–type” Initiative under KMA leadership.
The KMA can convene relevant specialty societies to develop Kenya-specific guidance on “high-value” vs “low-value” investigations — including laboratory and radiology tests.
– These guidelines should be evidence-based and adapted to local disease burden, resource constraints, and practice patterns.
– They should be made publicly available, for both clinicians and patients, to foster transparency and trust.
2. Promote Shared Decision-Making Involving Patients.
Patients should be informed if a requested test is not covered under their plan, or if it may not add clinical value — and be given the option (with financial consent) if still indicated by their doctor. This empowers patients, avoids surprises in billing, and reduces conflict between insurer and clinician.
3. Encourage Use of Diagnostic-Stewardship Frameworks in Hospitals and Clinics.
– Implement clinical decision-support tools (e.g. order sets or algorithms) to guide test ordering based on diagnosis, indication, and timing — rather than reflexive or routine ordering.
– Use lab information systems and utilization-management alerts (e.g. warnings for duplicate or recent tests) to avoid unnecessary repetition or redundant testing. This approach has been shown to reduce overuse while preserving quality of care.
– Periodic audit of laboratory utilization (by hospital management, labs, or even payers) but focusing on quality and clinical appropriateness, not punitive denial of necessary care.
4. Regulate Roles and Boundaries of Insurers.
– Insurers should not unilaterally dictate which tests a physician may or may not order, unless this is embedded within mutually agreed clinical-practice guidelines or protocols developed collaboratively with practitioners.
– Instead of dictating care, insurers can play a supportive role: they can provide coverage “menus,” decision-support (based on agreed guidelines), and transparent communication to patients about what their premiums cover.
– Regulatory oversight through national bodies like the Insurance Regulatory Authority (IRA) should ensure insurers’ practices respect clinical autonomy and patients’ rights. Indeed, the regulatory framework for private health insurance in Kenya already emphasizes protection of insured persons’ interests and transparency of policy terms.
5. Foster Dialogue, Trust-Building and Professional Self-Regulation.
– The KMA (and other professional bodies) should engage insurers, laboratories, hospitals, and patients in regular forums to discuss utilization, costs, quality, and shared challenges — rather than leaving decisions solely to insurers.
– Emphasize that proper stewardship doesn’t equate to rationing: the priority is clinical benefit and patient-centered care.
– Encourage self-regulation among clinicians (e.g. by peer review, audit, and feedback), and among insurers — with transparency in prior authorization policies, coverage limits, and exception processes.
Why This Balanced Approach Matters — And What Risks It Helps Avoid
• Respects clinical autonomy: Doctors remain free to order investigations they deem necessary, but guided by evidence and patient context.
• Avoids waste and overutilization: By aligning test ordering with clinical need and evidence, unnecessary or redundant tests are minimized, reducing costs while preserving quality.
• Promotes trust: Transparent, collaboratively developed guidelines and shared decision-making rebuild trust between clinicians, insurers and patients.
• Empowers patients: When patients are informed about what their insurance covers (and what it doesn’t), they can better participate in the decision-making around investigations, reducing surprises and conflicts at billing time.
• Supports sustainability: In a resource-constrained environment, judicious use of diagnostics helps keep insurance premiums manageable and ensures the long-term viability of insurance-based care.
Conversely, a regime in which insurers unilaterally impose rigid restrictions on test ordering, or refuse to pay for clinically justified tests, risks undermining patient care, eroding clinician motivation, and stoking adversarial relationships.
Lessons from Abroad — What We Can Learn
The global experience, notably through the Choosing Wisely movement, demonstrates that it’s possible to combine cost-consciousness with patient-centered, evidence-based care.
But the success of such initiatives rests not on top-down cost-cutting, but on clinician-led, guideline-driven, patient- oriented stewardship. Countries that have implemented diagnostic-stewardship frameworks report reductions in low-value testing without compromising care, and sometimes improving diagnostic accuracy and patient satisfaction.
This confirms that what is required is not a battleground between doctors and insurers, but a partnership in which all stakeholders (doctors, insurers, labs, patients, regulators) collaborate to define what “appropriate care” means.
Conclusion & Recommendations
The challenge of reconciling clinical autonomy with cost containment and sustainability is real and urgent. The recent advisory by an insurance company demanding prior authorisation for CRP (and likely other tests) highlights the urgency of confronting this challenge — but also the danger of allowing unilateral, insurer-driven restrictions.
The Kenya Medical Association to lead a locally-adapted “Choosing Wisely” style initiative, in partnership with insurers, laboratories, hospitals, and patient representatives. Through jointly developed evidence-based guidelines, transparent communication with patients, and diagnostic stewardship within institutions, we can achieve a balance: ensuring patients receive the investigations they truly need, while avoiding wasteful or unnecessary testing that drives up costs.
In doing so, we protect clinical autonomy, improve quality of care, preserve trust, and promote the long-term viability of insurance-based healthcare in Kenya.
Dr Simon Kigondu is a gynaecologist and the President of Kenya Medical Association.