Tuesday, December 6, 2011

Medical Necessity, Revisited

Several months ago, I wrote about the intricacies of "medical necessity" - the criteria insurance companies use to determine whether to pay for treatment. Most basically, treatment is deemed "medically necessary" if:
1) there is a diagnosable (i.e., DSM or ICD classified) mental disorder, with evidence of specific symptoms supporting the diagnosis.
2) the mental disorder causes significant impairment in functioning, in areas such as social, occupational, educational, self-care, and judgment
3) the proposed treatment is consistent with accepted standards based on disorder and level of impairment

Ideally, it boils down to this: the client has a mental health problem that is getting in the way of functioning; treatment is offered that is appropriate for the client and problem; treatment follows a plan and results in improvement. The treatment continues to be deemed medically necessary as long as there is some improvement in response to treatment, but symptoms and impairments continue.

Unfortunately, even this isn't always enough for insurance companies. I have been dismayed to have several conversations with insurance reviewers lately in which they were reluctant or unwilling to cover "medically necessary" treatment (i.e., diagnosis, impairment, clinically appropriate intervention, improvement in response to intervention, and continued impairment) - just because the client was ambivalent about recovery.

I've also written in the past about ambivalence...and so have people far wiser than I. An extensive body of literature has been developed around the centrality of ambivalence in all kinds of behavior change. Much of this literature hinges upon the Stages of Change model, which suggests that people go through five stages during the change process (though not necessarily in a linear fashion, and often several times before lasting change occurs):
1) Precontemplation - the person is not aware of, or at least not acknowledging, the existence of a problem or need for change 
2) Contemplation - the person is aware of the problem, but is torn between staying the same and changing (i.e., ambivalent) 
3) Preparation - the person has decided to make changes and is getting ready to act 
4) Action - the person is actually working on change 
5) Maintenance - the person is working on maintaining changes
Relapse - a return to an earlier stage (e.g., a resurgence of ambivalence) and/or reverting to pre-change behavior - can happen at any point, and the process of change resumes. The ultimate goal is to transcend the maintenance stage - to get to the point where the person no longer has to work on maintaining the change because it has become ingrained. Motivational Interviewing is largely designed to help people work through their ambivalence and progress through the stages of change.

The bottom line of all this is that ambivalence is absolutely normal and to be expected in the course of changing longstanding behaviors. Good treatment - treatment that adheres to acceptable standards in the mental health professions - works with this ambivalence and helps people to resolve it in a way that affirms life. I consider this early part of treatment absolutely necessary, because actual changes can't happen (or at least can't last) until ambivalence is addressed.

I find it deeply disturbing that insurance companies do not want to pay for treatment when the client is ambivalent. I find it even more disturbing when we consider that many behaviors that are a focus of treatment can cost people their lives - drugs, alcohol, eating disorders, self-injury.... If my client has a life-threatening problem and is on the fence about changing, I see treatment as beyond medically necessary - treatment is often the thing that tips the balance in favor of change, and therefore moves the client toward life-preserving change.

If an insurance company sends my client away until they're "ready" and 100% committed to change, what will the cost be? What will the literal cost be to the insurance company when that client keeps needing a higher level of care, and more importantly, what will the cost be to the client in lost relationships, opportunities, or even life itself?

I think it's time to redefine what we as a society consider medically necessary.

1 comment:

  1. Insurance companies make money by denying claims and treatment--it is a business model and not one that has the best interest of the patient at heart, unfortunately. A "good" financial year is one where they profited by denying sometimes as many as 50% of claims submitted. Even worse, sometimes patients assume if something is not covered by insurance that they must not need it, thereby letting insurance dictate treatment.