How Do Doctors Decide What Care is Necessary for Mental Health Problems?

Study of medical necessity determination in the United States and Canada

From 1992 to 1994, researchers at Harvard Pilgrim Health Care documented the implicit criteria used to determine "medical necessity" related to mental health, and the influences of financial incentives and organizational arrangements on medical necessity decisions.

Key Findings

  • In the field of mental health, adoption of a normal function model used for medical services should create a fair, realistic and affordable system to guide insurance coverage decisions.

  • The current practice of mental health clinicians' reasoning about medical necessity provides valuable guidance for future policy. The decision about medical necessity is a process of reasoning and judgments that involves the facts about the patient and treatment options, as well as largely unarticulated values.