Bergthold L A
Health Aff (Millwood). 1995 Winter;14(4):180-90. doi: 10.1377/hlthaff.14.4.180.
The term medical necessity has been mainly a placeholder in insurance plans for over thirty years. More recently, the national health care reform debate and litigation over denials of costly experimental treatments have broken the term out into open discussion about what a necessary service is and who should decide if it is covered. This paper summarizes the history of the term and its evolution from an insurance concept controlled by practicing physicians to a rationing tool used by insurance administrators. How did national reform efforts address this terminology, and how should we define medical necessity in a changing delivery system?
三十多年来,“医疗必要性”一词在保险计划中一直主要是一个占位符。最近,关于国家医疗保健改革的辩论以及围绕昂贵的实验性治疗被拒付的诉讼,使这个术语进入了关于什么是必要服务以及应由谁来决定其是否涵盖的公开讨论。本文总结了该术语的历史及其从由执业医生控制的保险概念演变为保险管理人员使用的配给工具的过程。国家改革努力是如何处理这个术语的,以及在不断变化的医疗服务体系中我们应该如何定义医疗必要性?