Defining Medical Necessity: Challenges and Implications

Introduction The concept of necessary services is deeply imbedded in the Canadian medicare system, despite the fact that it seems to defy clear analysis. Coming to grips with this concept seems crucial to the sustainability of the system. Some commentators are concerned that the rapid development of new, and increasingly expensive, therapies will bankrupt any government that attempts to pay for all services deemed to be necessary. Others cite the fact that medications prescribed by physicians are not insured as inescapable evidence that the system needs expansion because it already is already failing to meet its promise of providing necessary therapy to all Canadians. In this brief paper I will take a critical look at the different ways the concept of medical is used, and the work it does. I will focus, in turn, on each of the terms that make up the concept. My aim is not to provide the complete conceptual analysis which has eluded so many others. Instead I hope to illuminate the challenges that must be met if the concept is to continue to be useful in health care planning. I. The Ambiguity of Medical Necessity The term medically necessary suggests how we decide that a treatment is necessary. Determinations of necessity are made by practitioners. This is clearest in the individual case where a doctor judges whether any treatment is necessary for this patient. A system set up in this manner puts great power into the hands of physicians - power over the patient and over the health care system. (1) The patient's access to government-funded services is controlled by her physician. The overall costs of the system are greatly influenced by these judgments. To say that a service is necessary is also symbolically important: it is to say that the service is a necessity of a particularly important sort. An individual's necessity has a particularly strong claim on the public imagination. In the public mind necessity is in a class by itself, separate from any other necessity one might identify. It is a necessity which should not go unmet, even in an era of reduced government involvement is the provision of social services. If the government has an obligation to provide for any of the needs of its citizens, it surely has an obligation to meet needs. Any shift to a less evocative word risks losing this support for public payment. II. The Beguiling Simplicity of Medical Necessity Much of the discussion of necessity focuses on separating what is necessary from what is optional or elective. The analysis tries to distinguish people's genuine needs from their mere desires. Given that the patient has been accurately diagnosed as suffering from a condition (be it a crooked nose, infertility or erectile dysfunction), the question becomes: is it necessary for the condition to be treated? The very point of drawing this distinction is to decide whether treatment should be paid for out of the public purse. If only we can find the boundary between the necessary and the optional, we will have found a natural place to set the limit on what treatments are insured services. While most people are willing to help others meet their genuine needs through a publicly funded system, fewer feel any obligation to help others satisfy all of their desires. However, the move from the diagnosis of a condition needing treatment to an entitlement to insurance coverage for a treatment is often made too quickly. The fact that an individual has a need, even a diagnosed one, does not entail that the provincial health care plan has an obligation to pay for a particular treatment, or for any treatment at all. Sometimes an obvious need exists but, unfortunately, science has no effective treatment to offer. Imagine a patient who suffers from a life-threatening disease for which no proven therapy exists. …

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