Fairness and rationing implications of medical necessity decisions.
When healthcare coverage entails medical necessity review, patients, providers, payers, and government agencies must confront issues of fairness and rationing. To explore the ethical ramifications of medical necessity decisions, we provide 2 illustrative case. In the first case, we discuss the implications of rule-based rationing and in the second we consider the influence of a medical group's internal review council on decisions of medical necessity. Both case examples illustrate why there are no agreed-on rules for setting a threshold for approving or denying care based on medical necessity and suggest that more complex medical cases require a more complex review process.
Rosenblatt
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Harvard Medical School, Brigham and Woman's Hospital/Dana Farber Cancer Institute, Boston, MA, USA.
Harwitz
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DG
D003657:Decision Making; D004992:Ethics, Medical; D005260:Female; D015276:Health Care Rationing / Q000592:standards*; D006279:Health Maintenance Organizations / Q000592:standards; D006801:Humans; D019458:Insurance Coverage; D008297:Male; D020380:Needs Assessment; D014481:United States; D019564:Unnecessary Procedures; D014600:Utilization Review / Q000458:organization & administration*