Tuesday, November 27, 2007


Apropos of a discussion on Mark's blog about what sorts of perniciousness would follow from a universal (or, close to) health care plan, and in response to any notion that government sponsored health care is somehow more likely to micromanage the doctor-patient relationship, I offer this quote from my Blue Cross Blue Shield (BCBSTX) Explanation Of Benefits. The bold is in the original, the italics are mine:

Medically Necessary (Medical Necessity) - Services and supplies are considered medically necessary if they:

• Are essential to and consistent with the diagnosis or treatment of a specific illness or injury;
• Meet generally accepted standards of medical practice in the U.S.;
• Are not primarily for the convenience of the patient, physician, or hospital;
• Represent the most cost-efficient treatment of the condition that is safe and effective; and
• Are not experimental or investigational.

The recommendation of a physician or other health care provider does not automatically make a given service or supply medically necessary.

BCBSTX will determine whether a service or supply is medically necessary, considering views of the medical community, guidelines and practices of Medicare and Medicaid, and peer review literature.

1 comment:

Fox said...

And it's scary to think WHO at BCBSTX will be making that determination.

Having dealt with insurance companies at my work, I've encountered some of the ... how should I say ... "not very informed" people that are possibly making such decisions.

And I've also had some "not medically necessary" headaches in my personal life as well. It makes health insurance agents seem not unlike car insurance assessors. (Knock on wood... USAA has been very good to me.)

But still, I wonder how a universal/government-run system would improve - or worsen - these problems. Maybe the only way to answer that is to give it a try... I just don't know.