A huge amount of physician / provider time (cost) is dedicated to insurer billing, coding, and documentation.
I understand regulation plays a good role in that, but I can’t believe that it is the only reason..
Huge feature lists, high standards for correctness, strict regulations, existing long-term contracts.
It's like the space industry before SpaceX. Everyone knows the incumbent is inefficient, but you can't compete without building the whole damn rocket.
I think a substantial part comes from low risk tolerance and opting for high quality low volume care