Medical Necessity - American Health Lawyers Association

Special Presentation and Discussion:
Practice Variation and Medical Neccesity
Speaker:
John E. Wennberg, MD, MPH
Director, Center for the Evaluative
Clinical Sciences
Peggy Y. Thomson Professor for the
Evaluative Clinical Sciences
Dartmouth Medical School
Hanover, NH
After lunch the facilitator introduced
John E. Wennberg, MD,
MPH, physician and an epidemiologist,
for a special presentation
and discussion with the panel on
his research on unwarranted variations
in medical treatment—and
the potential for applying certain
findings from that research to the
development of a broad policy
approach to addressing medical
necessity. The panel discussed
both Dr. Wennberg’s findings and
an innovative proposal he subsequently
offered that would link his
research to the Colloquium
panel’s evident interest in policy
changes that would forge a partnership
between patients and
physicians in making treatment
decisions with implications for
medical necessity determinations.
This article summarizes Dr.
Wennberg’s luncheon presentation
as well as the panel’s discussion of
his innovative proposal. That
discussion mostly occurred during
the session that immediately
followed his presentation. (See,
“Stakeholders’ Concerns with the
Medical Necessity Claims
Adjudication Process—and
Suggested Solutions,” on pages 17-
20.) Recognizing that time did not
permit a full discussion of Dr.
Wennberg’s concept, a Health
Lawyers leader suggested at the
end of the Colloquium that the
Public Interest Committee work
with him to further develop the
proposal in the months ahead and
to share that work with the
Colloquium panel. Dr. Wennberg
graciously agreed.
Dr. Wennberg’s Presentation
Dr. Wennberg and his colleagues
at the Center for the Evaluative
Clinical Sciences have developed
the Dartmouth Atlas Project
(“Atlas”), an ongoing study of the
patterns of practice for beneficiaries
enrolled in traditional fee-forservice
Medicare. The Atlas is the
culmination of fifteen years of
research on the variations in
medical treatment provided
among 306 “hospital referral
regions,” which are aggregates of
smaller hospital service areas (see
Exhibit 1).
Dr. Wennberg explained that
researchers at Dartmouth have
defined three major categories of
medical services as a useful way of
viewing unwarranted variations in
treatment. Variations are judged
“unwarranted” if they cannot be
explained on the basis of illness,
patient preference, or evidencebased
medicine. The three categories
can be distinguished on the
basis of the relative importance of
four factors in clinical decision
making: medical evidence, clinical
theory, patient preferences, and
the local supply of healthcare
resources. The categories of
unwarranted variations in medical
treatment are effective care, preference-sensitive
care, and supplysensitive
care. 1 Dr. Wennberg
explained each category as follows:
Effective Care
This category refers to services
whose use is supported by wellarticulated
medical theories and
by strong evidence of efficacy in
the form of randomized clinical
trials or well-conducted cohort
studies. There are no trade-offs for
effective care—the benefits far
exceed the risk. “These are the
kinds of things that you could
write rules about,” Dr. Wennberg
explained. “If everybody has X
they should get Y. If they have a
heart attack, they should get a beta
blocker. Or, if they’re in a certain
age group, they should get an
immunization.”
Preference-Sensitive Care
This category refers to services in
which the medical decision
involves a choice between at least
two treatments with differing risks
and benefits. Sometimes, the
options are supported by strong
evidence of efficacy. Examples
include, Dr. Wennberg explained,
whether to perform a lumpectomy
or a mastectomy for breast cancer
patients, or, in the case of certain
non-cancerous prostate conditions,
whether to carry out procedures
where the trade-offs may be incontinence
or loss of sexual function.
Sometimes, the treatment decision
must be made in the face of
considerable scientific uncertainty
about the outcomes of care—for
example, the choice of surgery or
conservative management for lowback
pain.
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