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James C. Robinson, The Best Of Times And The Worst Of Times: A Conversation With Vicky Gregg, Health Affairs Web Exclusive, November 29, 2005 [Abstract] [PDF] [HTML Version] [Reprints & Permissions]

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Defining "Medical Necessity" In TennCare

Stephen S. Cha, Robert Berenson, Senior Fellow, Urban Institute   ( 23 January 2006 )

Defining "Medical Necessity" In TennCare 23 January 2006
Stephen S. Cha, Robert Wood Johnson Clinical Scholar Yale University, Robert Berenson, Senior Fellow, Urban Institute Send comment to journal: Re: Defining "Medical Necessity" In TennCare stephen.cha{at}yale.edu Stephen S. Cha, et al.	In James Robinson’s recent interview with Vicky Gregg of Blue Cross Blue Shield of Tennessee, Gregg mischaracterizes supposed innovations in TennCare’s new definition of medical necessity. While we support the movement towards evidence-based care and using cost-effectiveness criteria in deciding what services should be covered in insurance programs, the new TennCare medical necessity definition dangerously takes coverage decisions away from treating physicians and places them in the hands of state officials. We have both compared the TennCare definition to existing and proposed new definitions that would further evidence-based medicine, and one of us (Stephen Cha) recently testified on behalf of TennCare beneficiaries who could be harmed upon implementation of the new definition. First, the new language allows the bureau of TennCare to arbitrarily deny coverage to a majority of current care, if there is “inadequate empirically-based objective clinical scientific evidence.” Since much necessary and important care is not evidence-based,(1) this grants a state agency enormous latitude to overrule decisions of treating physicians on the basis of budgetary pressures or other such nonclinical factors. Second, the TennCare language incorporates cost, but does not clearly assess efficacy. The intervention must be the “least costly alternative course of diagnosis or treatment that is adequate for the medical condition of the enrollee,” again as determined solely by the bureau of TennCare. The definition of “adequate” is unclear in the statute and without strong legal precedent, again allowing enormous laxity to define covered care. In short, the TennCare medical necessity language is not an innovation in cost-effective or evidence-based policy, but instead falls in the time-honored category of attempts to limit care. The new and untested nature of this definition evades the discussion of the hardship of such limits, instead leaving patients and physicians guessing as to what will be cut in order to provide the massive savings the state hopes to achieve. Reference 1. Steinberg EP, Luce BR. "Evidence Based? Caveat Emptor!" Health Aff 2005; 24:80-92.