Although it is slowly becoming easier for the mentally ill to seek the help they need. The current amount of aid offered to those suffering from a debilitating mental disease. Is not nearly enough. Largely because the parameters to qualify for aid are not defined well enough. However, it is much easier to receive aid to begin with that to obtain aid, and then continue to receive aid until it is no longer needed. This is because the time when aid is no longer needed by the patient usually differs quite. Vastly from the time when the providers of said aid decide it is unnecessary. Insurance companies and hospitals are allowed to cut off aid once. They believe that treatment is no longer “medically necessary”. But this is usually very subjective, subject to bias, and mainly looks like it comes down to what will benefit the insurers the most.
According to the legally accepted definition of “medical necessity”, “Medical necessity is defined. As accepted health care services and supplies provided by health care entitie. Appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care.” This means that each patient’s care should reflect their condition, vary appropriately on a case-to-case basis, and assess each illness and treat it accordingly. It also breaks down what constitutes appropriate services and supplies, explaining that it should be the exact amount that a patient requires at a point in time. At first glance, this seems to prove a very sound definition for medical necessity, and doesn’t seem to leave much room for error. However, as medical necessity’s policy gets more and more in depth as to how each case should be assessed, it is clear that there is much room for bias.
As soon as the policy gets past a few more specifics, it reads, “Determinations of medical necessity must reflect the efficient and cost-effective application of patient care”. The introduction of this requirement also introduces the first idea of putting the patients needs second. By stating that it must reflect cost-effective application, it means that making sure a patient gets enough treatment is no longer the most vital concern. It’s essentially stating that the patient can get all of the care they need… as long as it’s not taking too much money out of the insurers’ and hospitals’ pockets. This also leaves a lot of room for subjection, because there is no set treatment-to-cost ratio, or way to decide the point at which a treatment is too costly to cover aside from the opinions of a bunch of directors or doctors on whether one patient’s treatment just isn’t showing enough progress for the money they’re putting into it.
Strangely, the policy goes on to say that the determination of necessity must be unrelated to the payer’s monetary benefit. This seems to contradict the previous clause, for if the determination was supposed to truly ignore monetary benefit, then a limit on treatment based on cost efficiency shouldn’t be necessary. This brings up many questions and concerns, such as which clause is taken into consideration more when deciding whether or not to cut off a patient’s treatment.
Regardless, the above reasons are most likely the cause of over a third of mentally ill individuals undergoing treatment ending up homeless within 6 months of their treatment ending. (SAMHSA) That is, one third of patients who, according to their doctors, had gotten all of the treatment that was deemed “medically necessary” and should have been ready to be functioning individuals. It appears that for the most part, the current policy and definition for “medical necessity” is too easy to abuse, and ends up, ironically, hurting the patients that should be getting treated.
If patients were getting the amount of treatment that was truly “medically necessary” then maybe there wouldn’t be so many discharges going right back to the way the started. Ideally, a just and ideal definition would give patients with debilitating mental illnesses enough treatment so that their mental illness would no longer be, well, debilitating. They should be able to receive enough aid to cover complete treatment of their illness, so that they may be able to lead a somewhat functional life, and not end up back on the streets.
Overall, the current definition of “medical necessity” leaves too much room for subjection, and is preventing patients from getting the help they need due to unjust limitations on the extent of aid they are able to get and the ability of insurers and hospitals to cut off aid based on what they believe is enough.
