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Related Experiment Videos

Medical necessity and psychiatric managed care.

W E Ford1

  • 1Health Systems Research, Inc., Washington, DC, USA.

The Psychiatric Clinics of North America
|July 26, 2000
PubMed
Summary
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Medical necessity definitions by insurers and government limit essential healthcare payments. Advocates must redefine these terms to improve access to quality mental health and substance abuse services.

Area of Science:

  • Health Services Research
  • Health Economics
  • Public Health Policy

Background:

  • Medical necessity is a key insurance contract and Medicaid provision limiting payments to essential treatments.
  • Third-party payers utilize medical necessity to manage financial risk and control healthcare spending.
  • Current definitions reflect insurer and government program philosophies, impacting coverage.

Purpose of the Study:

  • To analyze the role of medical necessity in healthcare coverage.
  • To explore the implications of medical necessity definitions for psychiatric and substance abuse (SA) services.
  • To identify challenges and strategies for healthcare advocates.

Main Methods:

  • Conceptual analysis of insurance contracts and government regulations.

Related Experiment Videos

  • Examination of the impact of medical necessity definitions on healthcare access.
  • Review of advocacy strategies for mental health (MH) and SA services.

    • Main Results:

    • Medical necessity definitions are tools for rationing scarce healthcare resources.
    • Expanding psychiatric coverage requires shifts in payer philosophies.
    • Even with parity, payers will use mechanisms to control demand and financial risk.

    Conclusions:

    • Short-term advocacy focuses on refining medical necessity definitions.
    • Long-term advocacy aims to create affordable, accessible quality care systems for all.
    • Systemic changes are needed to balance demand, resources, and financial risk in healthcare.