FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 340:229-232 January 21, 1999 Number 3 Next

	Since this article has no abstract, we have provided an extract of the first 100 words of the full text and any section headings.

	Full Text Purchase this article Letters Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

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 . . . [Full Text of this Article]

Background

Problems with the Use of Generalized Evidence of Medical Necessity

Practical Limitations of Generalized Evidence

The Rigors of Science

The Need for National Reform

References

Related Letters:

Prophylactic Mastectomy in Women with a High Risk of Breast Cancer
Hamm R. M., Lawler F., Scheid D., Ernster V. L., Kuerer H. M., Hwang E. S., Esserman L. J., Boice J. D., Olsen J. H., Hartmann L. C., Schaid D. J., Sellers T. A.
Extract | Full Text  
N Engl J Med 1999; 340:1837-1839, Jun 10, 1999. Correspondence

Who Should Determine When Health Care is Medically Necessary?
Newcomer L. N., Eddy D. M., Serota S. P., Rosenbaum S., Frankford D. M., Moore B.
Extract | Full Text  
N Engl J Med 1999; 341:58-60, Jul 1, 1999. Correspondence

This article has been cited by other articles:

• Spatz, E. S., Ross, J. S. (2009). Mis-SHAPEing Public Health Policy. Circ Cardiovasc Qual Outcomes 2: 681-683 [Full Text]  
• Rosenbaum, S. (2009). Insurance Discrimination on the Basis of Health Status: An Overview of Discrimination Practices, Federal Law, and Federal Reform Options.. J Law Med Ethics 37: 101-120  
• Clancy, C. M., Cronin, K. (2005). Evidence-Based Decision Making: Global Evidence, Local Decisions. Health Aff (Millwood) 24: 151-162 [Abstract] [Full Text]  
• Chung, P. J., Schuster, M. A. (2004). Access And Quality In Child Health Services: Voltage Drops. Health Aff (Millwood) 23: 77-87 [Abstract] [Full Text]  
• McCormick, D., Himmelstein, D. U., Woolhandler, S., Bor, D. H. (2004). Single-Payer National Health Insurance: Physicians' Views. Arch Intern Med 164: 300-304 [Abstract] [Full Text]  
• Austin, G. E., Burnett, R. D. (2003). An Innovative Proposal for the Health Care Financing System of the United States. Pediatrics 111: 1093-1097 [Full Text]  
• Sage, W. M. (2003). Unfinished Business: How Litigation Relates to Health Care Regulation. Journal of Health Politics, Policy and Law 28: 387-420 [Abstract]  
• Studdert, D. M., Gresenz, C. R. (2003). Enrollee Appeals of Preservice Coverage Denials at 2 Health Maintenance Organizations. JAMA 289: 864-870 [Abstract] [Full Text]  
• Rosenbaum, S. (2003). Managed Care and Patients' Rights. JAMA 289: 906-907 [Full Text]  
• Rosenbaum, S. (2002). Protecting American Health Care Consumers. JAMA 288: 2049-2050 [Full Text]  
• Gresenz, C. R., Studdert, D. M., Campbell, N., Hensler, D. R. (2002). Patients In Conflict With Managed Care: A Profile Of Appeals In Two HMOs. Health Aff (Millwood) 21: 189-196 [Abstract] [Full Text]  
• Rosenbaum, S., Kamoie, B. (2002). Managed Care and Public Health: Conflict and Collaboration. J Law Med Ethics 30: 191-200  
• Perneger, T. V., Martin, D. P., Bovier, P. A. (2002). Physicians' Attitudes toward Health Care Rationing. Med Decis Making 22: 65-70 [Abstract]  
• Morreim, E. H. (2001). From the Clinics to the Courts: The Role Evidence Should Play in Litigating Medical Care. Journal of Health Politics, Policy and Law 26: 409-428  
• O'Neal, L. W., Barham, F. L., Rakatansky, H., Wynia, M. K., Cummins, D. S., VanGeest, J. B., Wilson, I. B. (2000). Should Physicians Manipulate Reimbursement Rules to Benefit Patients?. JAMA 284: 1382-1383 [Full Text]  
• Frankford, D. M., Rosenbaum, S., Rosenblatt, R. E., Bystryn, J.-C., Kovner, V. L., Kapp, M. B., Studdert, D. M., Brennan, T. A. (2000). The Problems with Punitive Damages in Lawsuits against Managed-Care Organizations. NEJM 342: 1756-1758 [Full Text]  
• Morreim, E. H. (2000). Quality of Life: Erosions and Opportunities Under Managed Care. J Law Med Ethics 28: 144-158  
• Vladeck, B. C. (2000). Commentary. Med Care Res Rev 57: 235-242  
• Eisenberg, J. M. (1999). Ten Lessons for Evidence-Based Technology Assessment. JAMA 282: 1865-1869 [Full Text]  
• Newcomer, L. N., Eddy, D. M., Serota, S. P., Rosenbaum, S., Frankford, D. M., Moore, B. (1999). Who Should Determine When Health Care is Medically Necessary?. NEJM 341: 58-60 [Full Text]  
• Hamm, R. M., Lawler, F., Scheid, D., Ernster, V. L., Kuerer, H. M., Hwang, E. S., Esserman, L. J., Boice, J. D., Olsen, J. H., Hartmann, L. C., Schaid, D. J., Sellers, T. A. (1999). Prophylactic Mastectomy in Women with a High Risk of Breast Cancer. NEJM 340: 1837-1839 [Full Text]  
• Davidoff, F., Reinecke, R. D. (1999). The 28th Amendment. ANN INTERN MED 130: 692-694 [Full Text]  
• Burton, S. L. (1999). Why Liberals Should Embrace Managed Care. Journal of Health Politics, Policy and Law 24: 911-919  
• Mechanic, D. (1999). A Balanced Framework for Change. Journal of Health Politics, Policy and Law 24: 1107-1114  
• Frankford, D. M. (1999). Regulating Managed Care: Pulling the Tails to Wag the Dogs. Journal of Health Politics, Policy and Law 24: 1191-1200