Improving "medical necessity" acceptance by health care providers and consumers.

A major problem for patients and providers has existed since establishment of peer review and authorization agency medical necessity guide lines, because Physicians and patients who receive denial of proposed procedures and tests on the basis of so called "medical necessity" presume that the authorization agency considers the proposed procedure or test to be medically unnecessary, meaning of no health value to the patient. This may well not be the case. Both providers and consumers can be expected to be more accepting of negative authorization decisions if the principles of continuous quality improvement are brought to bear on the authorization process.

In today's health care environment, cost-effective alternative therapies with comparable outcomes have become the standard with many agencies and employer buyers of health care coverage. This does not necessarily mean that older more traditional therapies are wrong. Quality-of-life considerations play lesser roles in a decision-making process in which resources are effectively rationed. It is of note that all cosmetic plastic surgical procedures are considered medically unnecessary using the definition of the professional standards review organizations, in which "medical necessity" is defined as a medically necessary service, procedure, or level of care that is absolutely essential and indispensable for ensuring the health and safety of the patient. Another health care industry definition describes medical necessity as "care and treatment that is in accordance with the accepted standards of medical practice for the diagnosis and treatment of a covered sickness or injury; is delivered in the least intensive health care setting required by the coverage, sickness, or injury; and is not rendered solely for the patient's or his or her family's convenience or that of the health care provider."

Physicians and patients have a lack of understanding of the real benefits of medical necessity, peer review, and authorization agencies. Because of confusion regarding the term "medical necessity," a modern definition and categorization deleting the words necessity and denial is proposed. The benefits include relieving patient confusion and anxiety and reducing physician hostility, in that there is an inference that denial of a proposed treatment plan is based on a lack of medical necessity. The implication to the patient is that the physician is attempting to conduct procedures that are not necessarily in the patient's best interests.

Applying the CQI consumer-friendly methodology to the medical necessity authorization process, rather than the presently used QA police-like accusatory position, will defuse much of the anger and will have a much greater likelihood of obtaining the anticipated beneficial outcome without worsening the attitude of indignation, distrust, and hostility that the authorization-procedures currently generate in patients and physicians.

Many physicians and patients look upon medical necessity guidelines as an arbitrary decision-making process that inappropriately and unfairly interferes with the provider's ability to provide health care. The medical necessity umbrella, as it exists today, encompasses many controversial issues, including bioethics, resource allocation, and patient selection, that require greater categorization and better explanation. Using easily understood categories of approval or disapproval based on coverage benefits results in a more palatable and better accepted decision by those that the process affects. The proposed CQI process that addresses authorization issues from consumers' perspective is separated into four categories:

* Obligatory. Procedures and tests

that are necessary to save life and

limb and to prevent serious medical

conditions. Authorization for

conditions in this category is virtually

a certainty.

* Contingent. Procedures that may

or may not be approved, depending

on circumstances relating to 

the disorder. As an example, not

all patients with coronary heart

disease should undergo coronary

catheterization, angioplasty, or

CABG operations. Most patients

with degenerative disease of the

joints can be appropriately managed

without prosthetic surgery.

Likewise, asymptomatic cholelithiasis,

hernias, hemorrhoids, and

varicose veins should not receive

rubber stamped approvals. When

and if the disorder worsens, reconsideration

would be in order. Data

collection and informed decision

making by the authorizing agency

is of highest importance in this

category. Authorization is thus

conditional.

* Discretionary. Procedures that

may well be important and necessary

from the patient's viewpoint,

be they psychological or quality of

life issues, but that are not covered 

by health care policy benefits.

* Deleted. Procedures that are universally

considered outmoded,

obsolete, or hazardous and should

no longer be performed.

Because the words necessary and deny are removed from the authorization approval altogether, the entire process becomes more palatable and more likely to be accepted by physicians and patients alike. In this system, the word disapproved is substituted for denial in all correspondence to the patient and to physicians. Except for category four, the decision is made on the basis of lack of health care coverage benefits for the proposed procedure. The perception of denial for medical benefits is thus removed from the equation. If the patient and his or her physician wishes to proceed with a category three or four procedure in spite of disallowance by the authorizing agency, they may do so at their own expense and peril.

The Blue Cross/Blue Shield Association's medical necessity project, which had its beginnings in 1976, has served to establish appropriate standards in health care delivery and has done extraordinary well in this endeavor. The project was originally conducted to identify outmoded, obsolete, and hazardous procedures and tests. The study has been continually updated to evaluate the usefulness of established procedures, including routine admission tests, respiratory care, diagnostic imaging, cardiac care, ECGs, chest x-rays, and clinical laboratory tests.

Recommendations that have been developed by the Blue Cross/Blue Shield project and others in collaboration with qualified experts in their respective fields are recognized nationally, by both government and industry, as establishing improved standards for health care delivery in this country. However, the consumer and the health care provider frequently have personal perceptions that are at odds with agency recommendations.

Because perception is reality, changing medical necessity authorization from a QA policing process to a palatable CQI patient/provider process will lead to better consumer satisfaction and cooperation, while maintaining the basic integrity of the medical necessity concept and the agencies that follow its guidelines. 11

Further Reading

Frieswick, G., and Bach, D. "Physician Involvement in Clinical Efficiency Efforts Produces Long-Term Gains at University of Massachusetts Teaching Hospital. Strategies in Healthcare Excellence 6(8):1-9, , Aug. 1993

Nyman, J., and others. "Changing Physician Behavior: Does Medical Review of Part B Medicare Claims Make a Difference?" Inquiry 27(2):127-37, Summer 1990.