Letters

Defining medical necessity

To the Editor:

"Making Sense of Health Plan Denials" [June 2001, page 39] provided a helpful explanation of health plan denials. The definition of medical necessity has long been a contentious issue between practicing physicians and physicians who work for health plans or organizations responsible for utilization and quality management.

As physicians, we feel we rarely order things that aren't medically necessary, although we know that much of the testing and treatment we do hasn't been substantiated by evidence-based studies. In fact, many of us don't really know what is medically necessary.

Having been on both sides of the aisle has helped me to better understand the complex issues involved but hasn't brought forward any solution. I want patients to realize that although everything their physician suggests or orders may be medically reasonable and appropriate, it may not be considered medically necessary. However, I don't want to create patient distrust of physicians' recommendations.

When patients are denied payment for a physician-ordered service or treatment that they believe is medically necessary and the insurance company's reason for the denial is that the service or treatment is not medically necessary, patients may seek recourse though the court system or legislative action. Although this may be gratifying to the patients, it carries the potential for even greater danger in that attorneys, judges, juries of lay people and government agencies would be making decisions on what is or isn't medically necessary. In my opinion, this determination is best left to the medical community.

It troubles me that our profession has not tried to create a universal definition of medical necessity - one that is understood by patients, physicians and insurance companies alike and that can be applied in a fair and equitable fashion for the greater benefit of all concerned.

Leo M. Hartz, MD
Clarks Summit, Pa.

A malpractice suit "winner"

To the Editor:

I found "Coping With the Stress of Being Sued" [May 2001, page 41] very interesting. I was recently tried for malpractice and was one of the lucky 80 percent of physicians who "win." Of course, there is really no such thing as winning in these situations, but vindication is possible.

One thing the article didn't touch on was the considerable amount of time that passes between the initiating event, the summons and the trial (or settlement). My experience lasted five years from start to finish, including the three years that lapsed between the summons and the trial. Many sleepless nights compounded my irritability and made me less tolerant of patients - and in my case, residents as well. I discussed the situation in very general terms with my colleagues and residents so they understood what was occurring in my life. Now, I have prepared a presentation for residents so they can learn from my experience.

I hope this never happens again, but I have found it rewarding to be able to include in my licensure renewal and various insurance forms that I went to trial within the last year and won!

Kathi Clement, MD
Cheyenne, Wyo.

Lists welcome here

To the Editor:

I appreciated the practice management pearl "Patients With Lists" ["Tailoring New Physicians to Fit Your Practice," April 2001, page 39] and would like to offer some additional thoughts. Although many physicians dread patients' lists, I believe we should welcome them. Patients who bring lists have thought through what they want to accomplish at their visit (even if their plans are unrealistic), and they are less likely than others to add an "Oh, by the way" question as the doctor reaches for the doorknob.

On average, each patient has a list of three concerns, written or not. If the patient doesn't bring the list, the doctor has to elicit it. This can be done using a technique I learned from the American Academy on Physician and Patient (AAPP). Using this technique, the physician makes a friendly introduction and then says to the patient, "I see you are here about 'x' today. Were you hoping to cover any other topics at today's visit?" The physician then asks "Anything else?" or "Any other concerns?" until the patient has no other concerns to add. Finally, the physician and patient negotiate which problems will be managed today and which require another appointment. This technique helps uncover and manage the list and also helps prevent important problems from surfacing inappropriately.

After practicing this technique for the past couple of years, I know it works. It has improved my outlook toward the dreaded "list" by promoting honesty in negotiation, helping my patients maintain control and allowing me to be a good steward of my other patients' waiting time.

Kenneth P. Olson, MD
Eagan, Minn.

Copyright © 2001 by the American Academy of Family Physicians.
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