Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
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5 Medical Necessity and Use of Evidence
5 Medical Necessity and Use of Evidence
Pages 51-58
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From page 51... ...
Alan Garber, staff physician at the VA Palo Alto Health Care System and Director of the Center for Health Policy at Stanford University, delineated the differences between the application of medical necessity and the development of a benefit package. He reviewed some precedents related to medical necessity, specifically federal court rulings and a definition developed by a consensus committee con vened by Stanford University with its associated criteria including consideration of cost.
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From page 52... ...
not primarily for the convenience of the patient, physician or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease. For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgment.
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From page 53... ...
Stanford Definition of Medical Necessity Before the above-discussed court decisions, a Stanford University project brought together various stakeholders to generate a model definition of medical necessity intended for use both by private health plans and state Medicaid programs (Singer et al., 1999) (see Appendix C)
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From page 54... ...
as "a good example of a very public process with a great deal of opportunity for public input." While individual medical necessity cases cannot be subject to a public process as they involve individual patients and confidential information, there can be, Dr. Garber pointed out, a public process for "vetting the rules that are used to make medical necessity decisions" and establishing an appropriate appeal process.
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From page 55... ...
For example, he said, if payment changes put more financial risk on the shoulders of providers, then providers "will have more of a stake in ensuring that only effective care and necessary care is delivered, so medical necessity decision making may turn out to play a lesser role." The nation is, however, "years off from the time when medical necessity decisions will be unnecessary or much less prominent in determining which care is delivered." Dr. Garber concluded by noting that one of the greatest challenges for coverage policy and medical necessity decision making is how to account for individual variation in ability to benefit from an intervention.
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From page 56... ...
For instance, although there are well-established clinical guidelines on the necessity for and appropriate administra tion of hormone replacement therapy for transgender patients, the lack of clinical trials and systematic reviews supporting such treatment remains a barrier for many transgender patients in accessing coverage for treatment. Additionally, while clinical trials may establish research-based evidence, for example in pharmacological treat ment, they do not always adequately involve diverse racial and ethnic populations, women, children, or adolescents.
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From page 57... ...
2003. Decision aids for people facing health treatment or screening decisions.
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