Defining and Implementing Medical Necessity in Washington State and Oregon

Published in: Inquiry, v. 34, no. 2, Summer 1997, p. 143-154

Posted on RAND.org on January 01, 1997

by Peter Jacobson, Steven M. Asch, Peter Glassman, Karyn Model, John Hernandez

Read More

Access further information on this document at www.inquiryjournal.org

This article was published outside of RAND. The full text of the article can be found at the link above.

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, the authors found that few insurers or health care plans in the sample attempted to resolve the ambiguities inherent in defining medical necessity. More importantly, the results of this study 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. The authors conclude that medical necessity as an organizing principle for clinical practice decision-making is likely to continue to erode in a managed care environment.

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

Our mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior. To help ensure our research and analysis are rigorous, objective, and nonpartisan, we subject our research publications to a robust and exacting quality-assurance process; avoid both the appearance and reality of financial and other conflicts of interest through staff training, project screening, and a policy of mandatory disclosure; and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations, disclosure of the source of funding of published research, and policies to ensure intellectual independence. For more information, visit www.rand.org/about/principles.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.