Who Should Determine When Health Care is Medically Necessary?

Abstract

In the United States there has been a radical shift in the power to determine when health care is medically necessary and therefore covered by insurance. From the 1950s through the late 1970s, physicians' medical opinions largely dictated coverage and were rarely challenged by insurers. Physicians no longer have this extraordinary level of autonomy. Insurers now routinely make treatment decisions by determining what goods and services they will pay for. The line between clinical decisions about necessary medical care and decisions about insurance coverage is particularly blurred in managed-care plans. The power of insurers to determine coverage potentially gives them . . .

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