Medical Necessity: A Moving Target

Humans act for complex practical reasons but create rationales for their actions. However, when careful intellectual scrutiny is applied to a rationalization, it often crumbles and slips from one's grasp. So it is with "medical necessity," which Dr. Paul Chodoff discusses from a different angle beginning on page 1481.

We return to the practicalities to make sense of things. When President Clinton's health plan was being decimated, few people understood that the question was not whether health care reform would occur, but under whose control: government bureaucrats or insurance bureaucrats. Given adequate resources, this country would gladly support a universal right to optimal health care. But it can't, and neither can Canada, Germany, nor Sweden, which have been considered to have rational and economical universal health care systems. Inflation has entered their systems, though less dramatically than here, and they are developing their own modes of rationing, using their own versions of medical necessity.

What have our insurance companies contracted to pay for? Cynics might say "as little as possible"; that is true of some companies, but not of all. I do reviews for some managed care companies; our monthly teleconference of physician advisers is a serious, professional conversation that struggles with what kind and level of care is most appropriate for a case under discussion. It's clear that medical necessity is a moving target, as is "standard of care." Practically speaking, the closest we come to any understanding of medical necessity is a group of responsible physicians doing their best to apply reasonable standards, accepting that these standards will evolve over time, due to changing ways of thinking as well as new knowledge or technology.

Although I don't know what medical necessity, or Dr. Chodoff's "health necessity," is, I know that we physicians had the chance to be accountable to ourselves; we blew it. A few of us did so by being incompetent, a disturbingly larger number by being lazy or greedy (how many partial hospitalization programs existed before managed care?), and the vast majority by doing nothing. So accountability was taken away, and "medical necessity" became the rationale. We are now accountable to insurance bureaucrats. I also know that accountability itself is not a bad thing.

I tell my patients their insurance companies believe they contracted to pay for treatment of their depression, including minimizing risk of relapse, but not to help them relate better to their mates, raise baseline self-esteem, or be more gratified at work. These last improvements are on the patients' nickel. Interestingly, almost all my patients are willing to pay out of pocket for them. As long as the seriously and chronically mentally ill patients are provided for, I'm not sure I mind.