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The Center for Health Law and Policy presents
Therapeutic Coverage:
A New Approach to Medical Necessity?
Speaker: Professor William M. Sage, M.D., J.D., Columbia Law School
Monday, November 10, 2003, 4:00 – 6:00 p.m.
On November 10, the Center for Health Law and Policy presented a seminar on “Therapeutic Coverage: A New Approach to Medical Necessity?” Professor William Sage of Columbia Law School outlined his proposal for a new basis on which managed care companies and insurance companies should decide which medical treatments to cover. Expert practitioners in the field of health law and medical coverage decision-making then provided feedback on the proposal, and discussion was opened to the audience. BLS Professor Nan Hunter moderated the program.
Commentators included:
- Diane Archer, Senior Attorney and former Executive Director, Medicare Rights Center
- Jeff Chansler, General Counsel of Group Health Inc
- Dr. Mick McGarvey, former Medical Director for Blue Cross/New Jersey
- Patti Weinberg, Island Peer Review Organization, an external review provider certified by New York State to decide appeals from denials of claims for medical care.
Professor Sage, who is also a physician, argued that the process of making insurance coverage decisions about which treatments satisfy the criteria for medical necessity should be modeled on the doctor-patient relationship. Using this approach, he criticized the system of independent reviews of claim denials instituted in almost every state as a result of the "patient bill of rights" laws as inappropriately adversarial, especially for persons who are chronically ill. Instead, he proposes a mediation approach in which insurer decisions would be bound less by contractual enforcement principles and more by an assessment of whether the coverage decision facilitated the overall therapeutic best interests of the patient.
The program was part of the Center's ongoing series of theory-practice seminars, in which scholars and practitioners have the opportunity to exchange ideas on important questions of health policy.
Read more about the Center for Health Law and Policy.
Read more about Professor William Sage.
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