DEFINING AND IMPLEMENTING MEDICAL NECESSITY IN WASHINGTON-STATE AND OREGON

This paper reports on a qualitative study of how health care providers in the states of Washington and Oregon define and implement medical n ecessity. Based on a series of semi-structured interviews, we found th at few insurers or health care plans in our sample attempted to resolv e the ambiguities inherent in defining medical necessity. More importa ntly, our results suggest that physicians in managed care plans were n ot using general definitions of medical necessity to make clinical dec isions, but instead relied on utilization management techniques to gui de the use of medical resources. We conclude that medical necessity as an organizing principle for clinical practice decision making is like ly to continue to erode in a managed care environment.