The ambiguity of health benefit contracts often has left insurers and providers prone to second-guessing. Moreover, fuzzy language such as "medically necessary" or "clinically appropriate" has triggered some nasty lawsuits.
For providers, the situation is even murkier now that more hospitals and physicians are becoming part of managed-care organizations that seek risk.
That's why the drive by the National Institute for Health Care Management to rework standard language in benefit contracts is a worthwhile idea. The institute, funded by a group of Blue Cross and Blue Shield plans, also boldly addresses cost-effective medicine.
Under its plan, procedures would be covered if:
The intervention is used for a medical condition.
There is sufficient evidence to draw conclusions about the intervention's effect on health outcomes.
The evidence demonstrates the intervention can be expected to produce its intended effects on health outcomes and outweigh its expected harmful effects.
It is the most cost-effective method available to address the medical condition.
Coming to grips with costs and rationing of care are necessary in a society that seeks to limit healthcare spending. While we support the institute's effort, rewriting of benefit contracts shouldn't be used as an excuse for insurers to deny care more easily, especially on financial grounds.
The work of this group should serve as an excellent starting point for a debate that's long overdue. But the project is doomed if it's viewed as dominated by insurer interests. The next-and perhaps most crucial-step is for advocates of patients and providers to add valuable input and balance to the process.