Ford W E
Health Systems Research, Inc., Washington, DC, USA.
Psychiatr Clin North Am. 2000 Jun;23(2):309-17. doi: 10.1016/s0193-953x(05)70161-1.
The concept of medical necessity is a provision of commercial insurance contracts and federal government Medicaid requirements that limits the payment to only those services that are essential for treating a person's sickness, injury, or condition. The concept of medical necessity is one tool used by third-party payers to contain their financial risk in a seemingly nonarbitrary manner. Also, the definitions of medical necessity used by commercial insurers or by the federal government reflect their product's or program's philosophies. Expanding commercial insurance or Medicaid psychiatric coverage would require changing those philosophies. As long as society is faced with a greater demand for health-related service than resources to meet them, such systems of rationing will be used. Even with full parity for psychiatric benefits, mechanisms will be used by payers to limit or control demand, thereby controlling financial risk. The short-term challenge for psychiatric advocates is to secure the most acceptable definitions of medical necessity from third-party payers. The long-term challenge for MH/SA advocates and for all health care advocates, is to develop a system that pays for the greatest number of quality services for the greatest number of people in need, in an affordable manner, regardless of diagnosis.
医疗必要性的概念是商业保险合同和联邦政府医疗补助要求的一项规定，它将支付限制在仅那些对治疗个人疾病、损伤或状况必不可少的服务上。医疗必要性的概念是第三方支付者以看似非任意的方式控制其财务风险所使用的一种工具。此外，商业保险公司或联邦政府所使用的医疗必要性定义反映了其产品或项目的理念。扩大商业保险或医疗补助的精神科覆盖范围将需要改变这些理念。只要社会面临的与健康相关服务的需求大于满足这些需求的资源，这种配给制度就会被采用。即使精神科福利实现了完全平等，支付者仍会采用各种机制来限制或控制需求，从而控制财务风险。精神科倡导者面临的短期挑战是从第三方支付者那里获得最可接受的医疗必要性定义。精神科/物质使用障碍倡导者以及所有医疗保健倡导者面临的长期挑战是，开发一个以可承受的方式为最大数量有需求的人支付最大数量优质服务的系统，而不论诊断如何。
