I ve been told that the doctor-patient relationship is a contract the patient comes to the doctor, receives a service, pays for the service, leaves. Older physicians have felt that the doctor-patient relationship is a covenant, a promise of continued responsibility not only for the visit, but for the course of the illness, if not a lifetime. After 40 years he finally realized that she was his patient and he had been her doctor throughout his career and her entire life. The erosion of significance is now built into the education of medical students and the socialization of residents. You can hear the discouragement and the painful reaction of young physicians to the daily undermining of their decision making and judgement.
Gatekeepers can countermand an order.
Formularies are designed to avoid more expensive drugs and when decisions are controversial, one must appeal to a peer who talks more like an insurance man than a physician. There are lots of sick people in need of quality medical care. That will never stop. In some way that is the answer to the questions just posed.