First published in Pharmacoeconomics, Volume 14, pages 27-48, 1998.

Also NBER Working Paper 6894, 1999

We present a methodology and database mediator tool for integrating modern knowledge-based systems, such as the Stanford EON architecture for automated guideline-based decision-support, with legacy databases, such as the Veterans Health Information Systems & Technology Architecture (VISTA) systems, which are used nation-wide. Specifically, we discuss designs for database integration in ATHENA, a system for hypertension care based on EON, at the VA Palo Alto Health Care System. We describe a new database mediator that affords the EON system both physical and logical data independence from the legacy VA database. We found that to achieve our design goals, the mediator requires two separate mapping levels and must itself involve a knowledge-based component.

What should be government's role in a market-oriented health care system?

What's the appropriate amount of regulation?

Who should regulate-states, federal government, or market forces?

What role do the courts play in this regulation?

Are there existing models that might guide leaders in designing an effective regulatory structure?

Welcome to the great managed care debate. In Regulating Managed Care, twenty-six of the nation's leading health policy experts give health care administrators, clinicians, and policy makers insight into the issues behind this critical exchange and provide leaders with a road map to assess the policy options available to protect the quality of our health care delivery system.

Medical Necessity was not a problematic issue when remote third party payers rarely challenged physicians' decisions and reimbursed physicians for whatever procedures they chose to order and perform. Over the past several decades, the term medical necessity has served as an innocuous placeholder, enabling insurance plans and physicians to make judgments about coverage that were usually unchallenged. The fact that individual physicians practiced differently and that some practice variation may be inappropriate was revealed by the path breaking work of John Wennberg, MD and colleagues at Dartmouth Medical School. Awareness of these differences, combined with rising costs, drew attention to the way decisions were being made. Until recently, neither consumers nor their physicians were fully aware of the power of the term medical necessity to deny care. The idiosyncratic way that coverage decisions are made in health care organizations has led to variation that creates inequity for consumers, greater cause for appeal of denials, and more litigation.

The California HealthCare Foundation funded research at Stanford University's Center for Health Policy to help clarify the coverage decision making process and to identify variation in the way medical necessity is defined and used in making coverage decisions in California. This information was intended to help promote greater clarity and consistency in decision making and to reduce conflict and litigation.