| Year |
Author |
Title |
Source |
Summary/Abstract |
| 1992 |
Eddy, David |
Clinical Decision Making: From Theory to Practice. Applying
Cost Effectiveness Analysis, the Inside Story |
JAMA 268(18): 25752582 |
An account of how analysis of cost-effectiveness was used
to change practice guidelines on high and low osmolar radiographic contrast
agents at Kaiser. Difficulties with analysis and buy-in are discussed. The
general logistics of the analysis itself are described, as are the lines
of thought behind each step of the analysis.
|
| 1992 |
Hall, Mark, and Gerard Anderson |
Models of Rationing: Health Insurers' Assessment of Medical
Necessity |
University of Pennsylvania Law Review 140 U Pa.L.Rev. 1637
|
EXCERPTS:
... Tishna, I was told, had virtually no chance of surviving
the relapsed Wilms' tumor [of the kidney] from which she is suffering and
Blue Cross/Blue Shield had denied coverage for autologous bone marrow transplant
("ABMT") with accompanying high dose chemotherapy, a treatment which could
well prolong and quite possibly save her life and which, concededly, provided
her only realistic hope of either. ... In about a dozen similar cases, however,
judges have ruled that the use of ABMT is still experimental and denied
coverage. ... From a legal perspective, however, these rulings are merely
the latest in a long series of ordinary contract disputes over the interpretation
of terms such as "medical necessity" or "experimental," which determine
the coverage of health insurance policies. ... In addition to this humanitarian
objective, the courts have been concerned about the perceived unfairness
of a retroactive denial of coverage after a patient has relied on his physician's
advice and incurred a bill for treatment later found by the insurer to be
inappropriate. ... An assessment that a technology is "experimental" at
one time must be modified if additional research or clinical findings validate
(or repudiate) its effectiveness....
|
| 1993 |
Anderson, G. F., and M. A. Hall |
Medical Technology Assessment and Practice Guidelines: Their
Day in Court |
American Journal of Public Health 83:1635-1639 |
There is the expectation that outcomes research and the promulgation
of medical practice guidelines will be able to identify and hopefully reduce
the amount of unnecessary or inappropriate medical care through a variety
of methods, including utilization review. However, the courts for multifarious
reasons have frequently overturned past efforts by public and private insurers
to deny claims on the basis of formal technology assessments or practice
guidelines. This paper examines the court's reluctance to accept a variety
of technology assessment methods in coverage policy decisions. The paper
reviews the options that have been proposed to restrict judicial involvement
in the formulation of coverage policy and then proposes a new option that
employs a more precise taxonomy of medical practice assessment.
|
| 1994 |
Sabin, James E., and Norman Daniels |
Determining "Medical Necessity" in Mental Health Practice
|
Hastings Center Report 24(6):5-13 |
The authors posed the question, "Should mental health insurance
cover only disorders found in DSM-IV, or should it be extended to treatment
for ordinary shyness, unhappiness, and other responses to life's hard knocks?"
Through the use of six illustrative case studies, the authors examined the
reasoning behind the determinations of medical necessity. The article includes
a discussion of a recurrent conflict between "hard-line" and "expansive"
views of medical necessity, noting that it frequently reflects unrecognized
moral disagreement about the targets of clinical intervention and the ultimate
goals of psychiatric treatment. The authors present three models for defining
medical necessity and argue a defensible rationale for the "normal" model,
which comprises a target of a medically defined deviation intended to decrease
the impact of disease or disability. Three tests of medical necessity are
offered: (1) Does it make distinctions the public and clinicians regard
as fair? (2) Can it be administered in the real world? (3) Does it lead
to results that society can afford? In the authors' view, a typical medical
necessity definition in the "normal" model would be "those mental health
services which are essential for the treatment of a Member's mental health
disorder as defined by the DSM-IV in accordance with generally accepted
mental health practice." The authors conclude that the DSM-IV standard provides
workable boundaries for medical necessity definitions to the extent that
they are the result of a highly public process open to scientific scrutiny,
field testing, and repetitive criticism over time.
|
| 1994 |
Eddy, David M. |
From Theory to Practice: Rationing Resources While Improving
Quality: How to Get More for Less |
JAMA 272(10) |
EXCERPT: "[...] when determining the appropriate use of an
intervention, we will need to change our way of thinking from qualitative
reasoning to quantitative reasoning. To a great extent, the predicament
we face today is the result of qualitative reasoning that assumes that if
a practice might have any benefit it should be done-the "criterion of potential
benefit." Because this type of reasoning does not try to determine the amount
of value a practice provides-separating those with high value from those
with small value-it has left us with the large inefficiencies that we see
in our practices today. To take advantage of these inefficiencies, we will
have to develop better skills for quantitative reasoning. It is no coincidence
that every example in this article was studded with numbers; it is not possible
to determine how much benefit will be gained or how much cost will be saved
by a transfer without estimating the benefits or the costs.
"[...] we will need to change from focusing on individuals to focusing
on populations-from "individual-based" decision making to "population-based"
decision making. In particular, practitioners need to develop an allegiance
to the entire membership of the health plan. This will be difficult for
those who see themselves as serving as their patients' advocate in a struggle
with administrators and insurers. That perception is incorrect. When physicians
hoard resources for their own patients, they are not taking from administrators
or insurers; they are taking from other patients. If each practitioner is
concerned only about his or her individual patient, without concern for
the impact of his or her decisions on other patients, the result will not
be lower costs and higher quality, but higher costs and lower quality.
"If health plans and individual practitioners are to succeed in making
transfers that increase quality while reducing costs, they will need both
guidance and protection. Guidance will be needed to ensure that decisions
are consistent and have the desired effects. Protection will be needed to
defend both plans and practitioners when they make and implement controversial
decisions. The best way to address both those needs is to develop explicit
criteria that will sort out high-value practices from those that have little
or no value and will support transfers from one to the other. Currently,
the closest we get to such criteria are through vague and variable terms
such as "medically necessary" and "medically appropriate." But these are
far too vague and variably interpreted. If we are to control costs while
preserving quality, the first need is to develop better criteria for benefit
language."
|
| 1995 |
Bergthold, Linda A. |
Medical Necessity: Do We Need It? |
Health Affairs 14(4): 180-190 |
The term medical necessity has been mainly a placeholder
in insurance plans for over thirty years. More recently, the national health
care reform debate and litigation over denials of costly experimental treatments
have broken the term out into open discussion about what a necessary service
is and who should decide if it is covered. This paper summarizes the history
of the term and its evolution from an insurance concept controlled by practicing
physicians to a rationing tool used by insurance administrators. How did
national reform efforts address this terminology, and how should we define
medical necessity in a changing delivery system?
|
| 1996 |
Eddy, David |
Clinical Decision Making: From Theory to Practice. Benefit
Language: Criteria That Will Improve Quality While Reducing Costs |
JAMA |
The idea that benefit language is one of the most important
determinants of the quality and cost of care is at the core of this paper.
Sample language is supplied describing health intervention, medical condition,
health outcomes, sufficient evidence, and cost effectiveness. It is noted
that the criteria are interconnected and points to some of the shortcomings
of the proposed language.
|
| 1997 |
Gross, Joshua M. |
Promoting Group Psychotherapy in Managed Care: Basic Economic
Principles for the Clinical Practitioner |
International Journal of Group Psychotherapy 47(4):499-507
|
Knowledge of the basic economic factors underlying managed
mental health care directly impacts the clinical practitioners' ability
to make constructive changes in the system. To aid understanding this article
introduces the managed care marketplace model, the interactive relationship
between medical necessity and patient co-payment, and demand management
economics. The author encourages practitioners to develop strategies to
overcome specific economic obstacles that prevent the promotion of group
psychotherapy.
|
| 1997 |
Hester, Thomas W. |
Algorithms and the Medication Treatment of People with Serious
Mental Illness |
MASMHPD Research Institute Report |
The goals of this paper are to provide the reader with an
understanding and rationale for the appropriate use of treatment algorithms
for people with serious mental illness. It suggests effective strategies
for using treatment algorithms to improve the quality of treatment and to
increase the accountability of medication treatment. The paper also addresses
potential dangers in developing practice guidelines and provides advice
for avoiding these pitfalls. Issues related to legal matters and managed
care contracting are discussed briefly.
|
| 1997 |
Jacobson, Peter D., Steven Asch, Peter A. Glassman, Karyn
E. Model, and John B. Hernandez |
Defining and Implementing Medical Necessity in Washington
State and Oregon |
Inquiry 34:143-154 |
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.
|
| 1997 |
Moran, Donald W. |
Federal Regulation of Managed Care: An Impulse in Search
of a Theory? |
Health Affairs 16(6):7-21 |
Although there is growing demand for regulation of the managed
care industry, regulatory proponents have yet to articulate a clear theory
of regulation. Most observers acknowledge consumer information problems
that regulation could address, but there is no consensus regarding regulation
of the broader public concern about restrictive medical-necessity determinations
by health plans. Concerns about these issues-which fall within the gray
areas of divergent clinical opinion-may be difficult or impossible to address
by explicit regulation. If policymakers forbear on regulation of medical
necessity determinations, private market innovation may ultimately remedy
this problem.
|
| 1998 |
Anderson, G. F., and M. A. Hall |
When Courts Review Medical Appropriateness |
Medical Care 36(8):1295-1302 |
OBJECTIVES: The authors examined how the courts have responded
to public and private insurers' use of medical appropriateness criteria
to establish coverage and payment policies.
METHODS: A structured review of all federal and state court health insurance
cases decided between 1960 and June 1994 that involved a dispute involving
medical appropriateness was performed. A total of 3,215 published court
decisions were analyzed, of which 203 met the criteria of relevance and
124 explicitly mentioned medical appropriateness criteria. The main outcome
variable was whether the court ordered the insurer to provide coverage.
RESULTS: In 185 cases, a definitive decision was rendered, and the insurer
was required to pay in 57% of the decisions. Whether the insurer relied
on an assessment or not, whether the assessment process was formal or informal,
and who conducted the assessment did not appear to influence courts' decisions,
nor did the specificity of the coverage exclusion. Significant predictors
of courts ordering coverage were court jurisdiction, contract language assigning
discretion to the insurer, severity of patient's condition, and whether
the treatment appeared to work for the particular patient.
CONCLUSIONS: For practice guidelines to be accepted by the courts, it is
more important to focus on how insurance contracts are written than on how
medical assessments are performed. |
| 1998 |
Chodoff, Paul |
Medical Necessity and Psychotherapy |
Psychiatric Services 49(11):1481-1483 |
Managed care and, specifically, the need to conform to medical
necessity requirements have had a dramatic effect on the medical and psychiatric
practice, especially on psychotherapy. The author describes the progression
of the concept of medical necessity from a simple accounting of services
reimbursable by insurance companies to an ambiguous term without definitional
consensus. He describes its relationship to the medical model and discusses
the incongruity between medical necessity and certain aspects of psychotherapy.
He proposes a broader concept-health necessity-based on an evaluation of
the advantages, disadvantages, and costs of medical and psychiatric services. |
| 1998 |
Ford, William |
Medical Necessity: Its Impact in Managed Mental Health Care
|
Psychiatric Services 49(2):183-184 |
Discusses the impact of managed care medical necessity definitions
on psychiatric care. Points to some possible reasons why BHMOs focus on
cutting short-term costs rather than managing long-term costs, including
short contract terms and labor-intensive reviews. |
| 1998 |
Miller, Monica |
Research: The Debate Over Medical Necessity in Case Law and
Government/ Industry Forums |
Foundation for the Advancement of Innovative Medicine Report
|
The report reviews the terms medical necessity' and medically
necessary care' as they are discussed in New York case law. They contend
that the judicial, contractual, and statutory developments in New York created
a standard of care that was lower than the negligence standard. |
| 1998 |
Mohl, Paul C. |
Medical Necessity: A Moving Target |
Psychiatric Services 49(11):1391 |
Letter from the editor discussing physician culpability in
engendering HMOs and medical necessity definitions. |
| 1998 |
The National Health Law Program |
Medical Necessity Definition Model Medicaid Managed Care
Contract Provisions |
The National Health Law Program Report |
Provides NHeLP's model medical necessity language. |
| 1998 |
Olson, Kristi |
The Threat of Evidence-Based Definitions of Medical Necessity
|
The National Health Law Program Report |
Discusses possible consequences of using an evidence-based
standard for determining medical necessity. It points to the fact that many
commonly used practices will fail to meet evidence-based criteria. It also
is concerned that minority groups, children, and women, who are historically
limited in access to care and trials, will suffer disproportionately under
evidence-based criteria. |
| 1998 |
Rosenbaum, Sara, et al. |
Negotiating the New Health Care System: A Nationwide Study
of Medicaid Managed Care Contracts |
Center for Health Services Research and Policy |
Contains compiled list and analysis of medical necessity
definitions contained in state Medicaid managed care contracts. |
| 1999 |
Bergthold, Linda A. |
Testimony to the US Senate Committee on Health, Education,
Labor, and Pensions: Medical Necessity: From Theory to Practice |
US Senate Committee on Health, Education, Labor, and Pensions
Report |
Policy paper discussing the problems inherent in defining
the term "medical necessity." She points out that the process by which decisions
are made is far more important to understand and improve than the terminology
used to describe those decisions, that there is substantial variation in
the way medical necessity is defined and used in private contract, and that
there is considerable discrepancy between contractual definitions and the
way those definitions are applied in practice. Her final recommendation
is that the Senate not define the terms in statute. Rather they should appoint
a broader group of stakeholders to take on the task. |
| 1999 |
Berman, Steve |
Measuring and Improving the Quality of Care of Health Plans
|
The Joint Commission Journal on Quality Improvement 25(8):
434-442 |
BACKGROUND: More than 200 health care policymakers and researchers,
clinicians, quality professionals, and other representatives of managed
care organizations, government, and academia attended the fifth annual Building
Bridges conference, "The Health Care Puzzle: Using Research to Bridge the
Gap Between Perception and Reality," in Chicago, April 11-13, 1999. Sponsored
by the American Association of Health Plans and the Agency for Health Care
Policy and Research-and now, the Centers for Disease Control and Prevention-these
annual conferences are intended to promote research in measuring the quality
and effectiveness of the services health plans provide. Selected plenary
sessions from the conference are represented in this report. KEYNOTE ADDRESS:
"Three worthy objectives" for managed care-harmonize practice guidelines,
develop evidence-based co-pays or price structure for drugs, and demystify
medical necessity-were discussed. PLENARY: A POPULATION HEALTH PERSPECTIVE:
Population-based care is designed to identify effective clinical and service
interventions and ensure their efficient delivery, identify ineffective
interventions and minimize their use, and monitor outcomes and change practice
if outcomes are sub-optimal. Yet certain questions need to be asked about
how to put this strategy in place, especially, "Why should any individual
or potential patient be willing to be treated in a population-based delivery
system?" THE FINANCIAL AND SCIENTIFIC EVIDENCE BEHIND PREVENTION: The concepts
of scientific evidence and financial evidence for prevention were reviewed
and applied in scenarios of the effectiveness and cost-effectiveness of
selected preventive care services. Education efforts are needed to promote
the use of effective interventions and encourage questioning of interventions
with unproven or less important effectiveness and poor cost-effectiveness. |
| 1999 |
Corlin, Richard |
Statement of the AMA to the Committee on Health, Education,
Labor and Pensions, United States Senate |
American Medical Association |
Formal AMA statement before the Senate addressing the issue
of medical necessity. Emphasizes that the definition of medical necessity
will become the standard applied to all review decisions. Health plan definitions
may place barriers between patients and specialty care. They also leave
most of the medical decision-making discretion with health plans as opposed
to the patient's physician. Recounts 1998 AMA consensus definition of medical
necessity, using a prudent physician standard. It also mentions the health
plan practice of retroactive denials for rendered care, which the AMA believes
should also be addressed. |
| 1999 |
Hallam, K. |
Lawmakers Define Medical Necessity |
Modern Healthcare (3) |
Discusses federal medical necessity legislation in brief. |
| 1999 |
Ireys, Henry T., Elizabeth Wehr, and Robert E. Cooke |
Defining Medical Necessity: Strategies for Promoting Access
to Quality Care for Persons with Developmental Disabilities, Mental Retardation,
and Other Special Health Care Needs |
National Center for Education in Maternal and Child Health
Report |
Discusses medical necessity determinations in regards to
persons with developmental disabilities. The report has a flow chart showing
the dynamics of medical necessity decisions within current service systems.
It also provides its own specifications for determining medical necessity. |
| 1999 |
Macielak, Paul, and Monica Miller |
The Atomic Bomb Scare Over Defining Medical Necessity |
Health Lobby Letters |
Two letters regarding New York State's medical necessity
statute. The first opposes the statute because of concerns that it leaves
all medical decision-making in the hands of the physicians and eliminates
the plan's abilities to conduct utilization reviews. The second letter is
a rebuttal that attempts to debunk the first point-by-point. |
| 1999 |
Rosenbaum, S., D. Frankford, B. Moore, and P. Borzi |
Who Should Determine When Health Care Is Medically Necessary?
|
The New England Journal of Medicine 340(3):229-232 |
In the authors' view, an insurer should be able to set aside
the recommendations of a treating physician only in restricted circumstances.
Decisions about coverage should continue to be weighed against clinically
accepted standards of medical practice. An insurer's decision should be
lawful only if the insurer can prove that the decision rests on valid and
reliable evidence that is relevant to a patient's individual circumstances.
The authors advocate neither a return to total autonomy for treating physicians
in determining insurance coverage nor a system in which insurers decide
on coverage according to criteria that are totally independent of professional
standards of clinical practice. Rather, they propose maintaining the middle
position represented by current law. This middle position requires insurers
to act reasonably and weighs the reasonableness of their conduct against
professional standards of practice as reflected by valid and reliable evidence. |
| 1999 |
Rovner, Julie |
Medical Necessity Takes Center Stage |
Business and Health (26) |
Discusses the general background of the current medical necessity
debate in brief. |
| 1999 |
Singer, Sara J., Linda A. Bergthold, Carol Vorhaus, Alain
Enthoven, et al. |
Decreasing Variation in Medical Necessity Decision Making
|
Stanford University Report |
This is an in-depth report looking into the question of medical
necessity. It deals with the variation and inconsistencies of definitions
that the various stakeholders have. It notes a paucity of research regarding
health plan decision-making and whether medical necessity definitions play
a real role in decision-making. It documents a number of conferences and
original research, eventually concluding with a consensus for a model decision-making
process and medical necessity definitions. It concludes by reviewing the
various stakeholders, their concerns, and what actions they could take to
decrease medical necessity variability. |
| 2000 |
Allen, Kathryn |
Employers' Mental Health Benefits Remain Limited Despite
New Federal Standards |
United States General Accounting Office Report |
This report examines the implementation and effects to date
of the federal parity law, and focuses on: (1) employers' compliance and
the changes made to their health benefit plans, (2) what is known about
the costs of complying with the law, and (3) the oversight roles of HHS
and DOL in enforcing the law. In brief, they found that most employers comply
with the law; however, they have become more restrictive in the number of
hospital days or outpatient visits covered for mental health when compared
with traditional medical benefits. Few employers reported that the law has
resulted in higher costs. Finally, the recent laws have expanded DOL's role
in regulating health benefits. |
| 2000 |
Health Insurance Association of America |
"Medical Necessity" and Health Plan Contracts |
Health Insurance Association of America Report |
This policy piece scripted on behalf of the HIAA highlights
the problems of allowing medical necessity to be defined by physicians rather
than insurers. Essentially, it argues that legislation changing the status
quo would: (1) undermine utilization management and increase costs, (2)
encourage fraud and abuse, (3) undermine quality and perhaps even expose
patients to danger, and (4) undermine contract law. In the end they conclude
that placing determination powers back squarely in the hands of providers
will simply undo all the progress made in health care since its departure
from widespread fee-for-service arrangements. |
| 2000 |
Apgar, Kristen Reasoner |
Large Employer Experiences and Best Practices in Design,
Administration, and Evaluation of Mental Health and Substance Abuse Benefits:
A Look at Parity in Employer-Sponsored Health Benefit Programs |
Office of Personnel Management Report |
Prepared for OPM, this report described how large corporations
were structuring their insurance plans in order to deal with new mental
health parity legislation. It discusses a ?big picture' approach, reportedly
focusing on keeping employees healthy and well in order to avoid later problems
with absenteeism, disability, and lost productivity. Eight employers were
studied: American Airlines, AT&T, Delta Airlines, Eastman Kodak, IBM, General
Motors, the Massachusetts Group Insurance Commission, and PepsiCo. They
highlight what they believe to be essential mechanisms to providing parity
in care as well as identify problematic areas. The author discusses the
use of managed behavioral care carve-outs. The document ends by making recommendations
regarding how OPM should structure future insurance programs. |
| 2000 |
Fleishman, Martin |
What is Psychiatric "Medical Necessity"? |
Psychiatric Services 51(6): 711-712, 719 |
This article reviews AMA's definition of medical necessity
and points out problems of its application to psychiatry. It also recommends
its own definition for psychiatry after a discussion of HIPAA law and possible
implications for fraud in psychiatry. |
| 2000 |
Ford, William |
Medical Necessity and Psychiatric Managed Care |
Psychiatric Clinics of North America 23(2):309-317 |
The concept of medical necessity is a provision of commercial
insurance contracts and federal government Medicaid requirements that limits
the payment to only those services that are essential for treating a person's
sickness, injury, or condition. The concept of medical necessity is one
tool used by third-party payers to contain their financial risk in a seemingly
non-arbitrary manner. Also, the definitions of medical necessity used by
commercial insurers or by the federal government reflect their product's
or program's philosophies. Expanding commercial insurance or Medicaid psychiatric
coverage would require changing those philosophies. As long as society is
faced with a greater demand for health-related service than resources to
meet them, such systems of rationing will be used. Even with full parity
for psychiatric benefits, mechanisms will be used by payers to limit or
control demand, thereby controlling financial risk. The short-term challenge
for psychiatric advocates is to secure the most acceptable definitions of
medical necessity from third-party payers. The long-term challenge for MH/SA
advocates and for all health care advocates, is to develop a system that
pays for the greatest number of quality services for the greatest number
of people in need, in an affordable manner, regardless of diagnosis. |
| 2000 |
AMA Private Sector Advocacy Group |
Medical Necessity |
AMA Private Advocacy Group Report |
This document contains the AMA model definition of medical
necessity and discusses the need for providing a definition that reflects
a clinical determination rather than a business determination. |
| 2000 |
Hill, Hugh, Annette Hanson, and Brent O'Connell |
Coverage Decisions |
AHRQ User Liaison Program Report |
This report summarizes a session that evaluated the processes
for making coverage decisions in private, State, and Federal venues. Highmark
Blue Cross Blue Shield describes their decision-making process, built around
a contractual definition of medical necessity,' which it provides. The Massachusetts
Medicaid model is based on statutory definitions of medical necessity and
evidence-based assessments of new interventions. HCFA is also described,
drawing its authoritative powers from section 1862 of the Social Security
Act. Services or technologies that fulfill the criteria of the definition
are divided into 55 statutorily defined benefit categories. |
| 2000 |
Landau, Morris |
The Difficulties in Defining Medical Necessity |
Health Law and Policy Institute Report |
This short briefing on the nature of the current difficulties
in defining medical necessity concludes that a comprehensive approach that
differs from third party rationing should be used in forming a decision. |
| 2000 |
Sabin, James, and Norman Daniels |
Public-Sector Managed Behavioral Health Care: V. Redefining
"Medical Necessity"-The Iowa Experience |
Psychiatric Services 51(4):445-459 |
This article discusses psychiatric problems with medical
necessity definitions and expresses a need for psychosocial necessity' expansion.
It reviews Iowa's experience with managed behavioral health care and prognosticates
that psychiatrists will be forced to opt out of the outpatient treatment
of the severely mental ill due to current BHMO policies. |
| 2000 |
Satcher, David |
Mental Health: A Report of the Surgeon General |
United States Public Health Service Report |
This comprehensive report gives detailed background into
many facets of mental health care. Chapter 6, "Organizing and Financing
Mental Health Services," gives an in-depth analysis of the economic structure
and costs of modern mental health care with comparisons to traditional medical
health care. The document also examines the issue of mental health parity,
looking at legislative trends and costs. Throughout the document, however,
there is no discussion of mental health medical necessity. |
| 2000 |
American Psych Systems |
American Psych Systems Provider Packet |
American Psych Systems Provider Packet |
This packet of materials sent to psychiatric providers contains
newsletters about recent changes, a complete copy of the updated Utilization
Management criteria, and a copy of policies and procedures regarding coordination
of care and provider appeals. Medical necessity is defined in loose terms
for each condition; however, a separate set of admission criteria also must
be met prior to admitting a patient for a psychiatric condition or continuing
care for a protracted period of time. |
| 2001 |
National Committee for Quality Assurance |
Standards and Surveyor Guidelines for the Accreditation of
MBHOs |
National Committee for Quality Assurance MBHO Handbook |
These are the published guidelines used by NCQA to accredit
MBHOs. Definitions of medical necessity are not suggested by NCQA; the MBHOs'
definitions simply must be accessible and include procedures for applying
criteria based on the needs of individual patients and characteristics of
the local delivery system. NCQA does define medical necessity denial and
underscores the need for MBHOs to use clinical practice guidelines. |
| 2001 |
Cleary, Patrick |
Benefit Mandates |
National Association of Manufacturers Letter |
Letter to Senator Gregg on behalf of National Association
of Manufactures. The letter speaks out against S 543, the Mental Health
Equitable Treatment Act of 2001. They argue that the new bill would greatly
expand the parity laws of 1996 and would have many drawbacks. Costs would
increase, while other benefits would be reduced to meet the bill's requirements.
They argue that there are no discernable limits to the scope of potential
coverage. They also voice concern over the bill's preemption provisions
that would preserve State legislation and extend it to ERISA plans. |
| 2001 |
Eddy, David |
How Evidence-Based Balance Sheets Can Help Make Decisions
|
Kaiser Permanente Report |
The author discusses the use of balance sheets and evidence-based
medicine for clinical decision-making. He points to their ability to summarize
in one place all the critical information needed to make decisions as a
great strength. |
| 2001 |
Fleishman, Martin |
Medication Management, Medical Necessity and Residential
Care |
Psychiatric Times XVIII:3 |
This article considers the difficulties of applying medical
necessity definitions, including the AMA-APA definition, to the unique needs
of the field of psychiatry. The term for convenience' is found to be a potential
obstacle to providing psychiatric care. The paper also laments the lack
of a specified role for external contributions from families, social workers,
and non-professional caretakers. The article voices concern over the HIPAA
alterations that make penalization of providers for medical fraud. It points
to steeper fines, unclear definitions of medical necessity as its standard,
and the fact that no specific intent to defraud is necessary. |
| 2001 |
CCD Task Force |
A Strong and Consistent Definition of Medical Necessity Forms
the Core of Meaningful Patient Protections |
Consortium for Citizens with Disabilities Report |
Offers a proposed CCD medical necessity definition and discusses
the implications such definitions can have on the disabled. It discusses
the need to fabricate protections to ensure that patients with disabilities
get the care they need. They point to a need to address functional ability
in any final necessity definition. |
| 2001 |
Joint Commission on Accreditation of HealthCare Organizations
|
2001-2002 Comprehensive Accreditation Manual for HealthCare
Networks |
Joint Commission on Accreditation of HealthCare Organizations
MCO Handbook |
This manual lays out the various rights of the beneficiaries,
response mechanisms, and ethical outlook that JCAHO evaluates in determining
if an organization receives accreditation. The guidelines do not offer any
standards for medical necessity definitions, but rather clearly define standards
regarding the medical decision-making process and information dissemination. |
| 2001 |
Havighurst, Clark |
Evidence: Its Meanings in Health Care and in Law. Summary
of the 10 April 2000 IOM and AHRQ Workshop |
Journal of Health Politics, Policy, and Law 26:2 |
The author reviews Jacobson's presentation entitled "Cost-Effectiveness
Analysis in the Courts: Recent Trends and Future Prospects." Of note, he
discusses making contracts more explicit with regard to the use of CEA in
coverage decisions. Havighurst mentions the possibilities of systematic
misrepresentation of benefits by insurers using this technique. |
| 2001 |
Regier, Darrel |
Statement of APA Executive Director to US Senate Health,
Education, Labor, and Pensions Committee on ?Parity for Mental Health Treatment'
|
American Psychiatry Association Report |
This APA report to the Senate on the need for mental health
parity legislation reinforces current understandings of the scientific basis
underlying the causal mechanisms of mental disorders and provides evidence
that parity insurance coverage is affordable, addresses a specific market
failure, and can support cost-effective treatment to reduce disability. |
| 2001 |
Singer, Sara J., and Linda A. Bergthold |
Prospects for Improved Decision Making About Medical Necessity
|
Health Affairs 20(1):200-206 |
Previous research has shown considerable variability in the
process and criteria used for decision making in both public and private
plans regarding medical necessity. This paper seeks to document differences
in decision-making criteria and to explain the relationship between contractual
definitions and the way decisions are made in practice. The investigators
used descriptions of best practices' and unacceptable variations' from health
plan interviews to provide insight into how medical necessity decisions
are made. They also produced a model contractual definition and decision-making
process based on best-practice models. |
| 2001 |
Sturm, Roland |
The Costs of Covering Mental Health and Substance Abuse Care
at the Same Level as Medical Care in Private Insurance Plans |
RAND Health Report |
Research paper delving into the issue of the cost for health
insurers to implement mental health parity. Their results suggest that parity
in employer-sponsored health plans is not very costly under comprehensive
managed care. Also data do not support excluding substance abuse from parity
efforts due to prohibitive cost, because decoupling mental health and substance
abuse care in terms of benefits cannot save any meaningful amount. These
results may not apply to unmanaged indemnity plans, and they may only hold
for large employers but not for individuals or for small groups buying insurance. |
