Jacobson P D, Asch S, Glassman P A, Model K E, Hernandez J B
Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor 48109-2029, USA.
Inquiry. 1997 Summer;34(2):143-54.
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, we found that few insurers or health care plans in our sample attempted to resolve the ambiguities inherent in defining medical necessity. More importantly, our results 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. We conclude that medical necessity as an organizing principle for clinical practice decision making is likely to continue to erode in a managed care environment.
本文报告了一项关于华盛顿州和俄勒冈州医疗服务提供者如何定义和实施医疗必要性的定性研究。基于一系列半结构化访谈，我们发现样本中的保险公司或医疗保健计划很少试图解决定义医疗必要性时固有的模糊性。更重要的是，我们的结果表明，管理式医疗计划中的医生并非使用医疗必要性的一般定义来做出临床决策，而是依赖利用管理技术来指导医疗资源的使用。我们得出结论，在管理式医疗环境中，作为临床实践决策组织原则的医疗必要性可能会继续受到侵蚀。
