HMO REFORM: ‘Medically Necessary’ Care Debated
A Senate committee heard testimony yesterday on the contentious topic of what constitutes "medically necessary" health care, with witnesses debating whether HMOs or doctors should set the standard. The American Medical Association's Dr. Richard Corlin told the Senate Health, Education, Labor and Pensions Committee that the medical necessity "standard is increasingly challenged by health plans that determine medical necessity primarily in terms of financial considerations" (AP/Newsedge, 3/3). Health Insurance Association of America President Chip Kahn countered, "These so-called patients' bill of rights proposals would give virtual carte blanche to treatments that are unnecessary. ... The result: consumers pay higher premiums and receive lower quality health care." He predicted that an overly vague definition of medically necessary care "would tie insurers' hands when fighting fraud and abuse. This is worse than hypocrisy -- this is public policy malpractice" (HIAA release, 3/3). He suggested that instead of government mandates, consumers should choose plans that offer independent appeals. "Consumer can walk with their dollars," he said. They're paying the premiums" (AP/Newsedge, 3/3). Testifying before the committee, the Rand Corp.'s Robert Brook noted 20% to 30% of patient care is unnecessary, and "patients do not receive one- third of the care they do need." He suggested "physicians and researchers need to better 'synthesize' evidence for the 60 to 100 'core medical procedures' to determine what care should or should not be delivered (Rovner/Morrissey, CongressDaily, 3/2).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.