Deciding what is 'medically necessary'

Ever since the introduction of publicly financed health care, funding decisions have been based, at least theoretically, on a determination of "medical necessity." A notoriously slippery concept, the term "medically necessary" can be found throughout Canadian health-care legislation. The Canada Health Act states all "medically required services rendered by medical practitioners" and all "medically necessary" hospital services must be publicly funded. The Alberta Health Care Insurance Act uses similar language. And numerous international instruments to which Canada is a signatory refer, either explicitly or implicitly, to a right to access a basic level of health care.

But despite the common use of the concept, no practical definition of "medically necessary" exists. Indeed, many commentators, such as well-known bioethicist Daniel Callahan, have argued an operational definition will always remain elusive: "Is it just an accident that all efforts to find meaningful definitions of 'adequate' or 'minimal' or 'necessary' have failed? The failure, I believe, is inevitable, inherent in the project itself."

Historically, a medically necessary service amounted to anything that physicians believed should be provided. Driven by a number of health-care trends, it is only recently that defining the parameters of medical necessity has become a major, if not-the major, health-policy issue. First, cost containment has emerged as a dominant goal of health-policy decision makers. In this context, a delineation of government's responsibility to its citizenry takes on heightened significance. Second, starting in the late 1980s there was a growing recognition no clear rationale, or scientific evidence, existed to justify the provision and coverage of many conventional health-care services. Indeed, many services were insured without any evidence they were effective. A recognition of this paucity of good information led both to the current trend toward "evidence-based medicine" and to a greater emphasis on the tie between efficacy and public coverage. Third, medical science is moving forward at a breathtaking pace. From new diagnostic technologies to an ever-increasing array of experimental cancer treatments, the medical profession simply has more to offer patients. And with each new medical discovery comes a decision about its public funding.

Timothy Caulfield

Finally, it has been noted the public system is increasingly strained by what some commentators have called "medical consumerism." Roy Porter, for instance, argues "the healthier western society becomes, the more medicine it craves. Indeed, it regards maximum access as a right and duty." While one can hardly consider the desire to access potentially life-saving treatment a form of "medical consumerism," the consumer trend affects the system as a whole and, as such, makes heartbreaking decisions increasingly necessary.

In the end, all of these forces will combine to create an environment where tough decisions seem likely to occur with more frequency. The recent decision by Alberta Health not to fund an experimental cancer treatment for U of A Professor Aleksandar Kostov is but one of many recent examples.

So, how should Canadian society respond? It seems certain that we should resist efforts to develop a simple list of insured services. Such an approach, as attempted in the state of Oregon, will inevitably be too rigid to respond to the needs of individual patients. A "decision-making framework" approach seems much more logical and just. For example, Professor Raisa Deber of the University of Toronto has suggested a "Four Screen Model" which includes a consideration of: efficacy (is there evidence the treatment works?); appropriateness (is this treatment appropriate for this patient?); informed decision-making (does the informed patient really want the treatment?); and broader policy concerns (are there reasons why this particular treatment should not receive public funding?).

We also need to carefully consider which health-care services we want to leave to the private sector. As many recent studies have demonstrated, a robust private health-care sector has the potential to erode the public system. This creates the ironic situation whereby decisions to not fund certain procedures may actually help to generate a market for private health care which, in turn, may put a strain on the very system we seek to protect.

Finally, and perhaps most importantly, we will need to recognize not all services, even potentially life-saving services, can be covered by a public system. Unfortunately, as the tension between individual needs and the public good becomes more acute, and as we hear more stories of treatments not being paid for by our public system, this recognition will become difficult for a compassionate society to reconcile. In the meantime, we can only hope these decisions are informed by the best available information and that they are made with full consideration to the goals of our health-care system and the expectations of Canadian citizens.