Defining and implementing medical necessity in Washington State and Oregon.
This paper reports on a qualitative study of how health care providers in the states of Washington and Oregon define and implement medical necessity. Based on a series of semi-structured interviews, we found that few insurers or health care plans in our sample attempted to resolve the ambiguities inherent in defining medical necessity. More importantly, our results suggest that physicians in managed care plans were not using general definitions of medical necessity to make clinical decisions, but instead relied on utilization management techniques to guide the use of medical resources. We conclude that medical necessity as an organizing principle for clinical practice decision making is likely to continue to erode in a managed care environment.
Jacobson
P D
PD
Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor 48109-2029, USA.
Asch
S
S
Glassman
P A
PA
Model
K E
KE
Hernandez
J B
JB
D003659:Decision Making, Organizational; D018588:Fee-for-Service Plans / Q000458:organization & administration*; D015276:Health Care Rationing / Q000592:standards*; D006301:Health Services Needs and Demand / Q000145:classification*; D006302:Health Services Research; D006801:Humans; D007345:Insurance Claim Review; D019458:Insurance Coverage; D008329:Managed Care Programs / Q000458:organization & administration*; D009922:Oregon; D010820:Physicians / Q000523:psychology; D011795:Surveys and Questionnaires; D014600:Utilization Review; D014861:Washington