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10 Health L. Rev. 6 (2001-2002)
Defining Medical Necessity: Challenges and Implications

handle is hein.journals/hthlr10 and id is 52 raw text is: Introduction The concept of medically 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, medical therapies willbankrupt any government that attempts to pay for all services deemed to be medically necessary. Others cite the fact that medications prescribed by physicians are not insured as inescapable evidence that the system needs expansionbecause it already is already failing to meet its promise of providing medically necessary therapy to all Canadians. In this brief paper I will take a critical look at the different ways the concept of medical necessity 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 service suggests how we decide that a treatment is necessary. Determinations of necessity are made by medical practitioners. This is clearest in the individual case where a medical 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 medical judgments. To say that a service is medically necessary is also symbolically important: it is to say that the service is a necessity of a particularly important sort. An individual's medical necessity has a particularly strong claim on the public imagination. In the public mind medical 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 edically necessary the provision of social Ortant: it is to say services. If the government has an obligation to provide necessity of a for any of the needs of its 1- citizens, it surely has an obligation to meet medical 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 medical 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 medical needs through a publicly funded system, 6 Health Law Review Defining Medical Necessity: Challenges and Implications Glenn Griener To say that a service is m is also symbolically imp that the service is a particularly important so, 6 Health Law Review

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