The Futility of Medical Necessity

he past few years in health care have been a story of extraordinary turbulence. After decades of uncontrolled cost escalation, the businesses and governments that directly pay for most health care finally mandated a fiscal restraint that, in the early 1990s, launched in earnest the upheaval known as “managed care.” One major result has been the replacement of such values as, “If it might help and won’t hurt, do it,” and, “Too much is better than too little,” with conservative edicts such as, “If you can’t demonstrate its value, don’t do it.” Virtually everyone can claim disenchantment with the upheaval in health care. Patients who expect their health plans to cover the latest tests and treatments are angry when their plans’ administrators refuse. Physicians must routinely justify their every medical move to outside parties and must be vigilant for the economic as well as the medical wisdom of their care. Employers, tantalized for a brief period by health plan premiums that were level if not actually declining, are now dismayed by the re-emergence of double-digit health care inflation. And health plans struggle to balance enrollees’ demands for the latest and greatest medical innovations against purchasers’ demands for controlled spending and lower premium prices, as well as societal demands that the plans promote the best interests of the broader population. This single article cannot begin to explore the causal latticework behind all of the disenchanting changes in the American health care system. But we can examine one major culprit: the notion of medical necessity. “Medical necessity” defines patients’ entitlements under various health plans: they can rightly expect their plans to cover T