We have something similar in Brazil. Our public system, SUS, has treatment protocols where you sometimes need to try drug A before you can get access to drug B. BUT the protocol is written by a medical committee - CONITEC -, not by an insurance company desperately trying to save money. When I need to skip a step, I write a lenghthy clinical justification and send it up. And it can take time, sometimes months. It's super frustrating, yes, but at the very least I know the person reviewing it is not incentivized to deny it. They are checking if my reasoning makes sense, not calculating how much it will cost their employer. That's the part that's hard to explain to Americans, that the bureaucracy here is slow and annoying but it's not adversarial. Nobody's profiting from telling me my patient doesn't need a medication. In the US model someone literally is. That changes everything about the practice.