Making the Definition of Medical Necessity Enter the 21st Century

Abstract

The purpose of this report is to explore the notion of medical necessity in Canadian healthcare systems and how politics can affect the determination of the basket of medical services that is publicly funded in each jurisdiction. An increase of effective medical practices will increase the quality of care, improve overall health, and improve the system's capacity for efficiency leading to a potential bend in the healthcare cost curve.1 Polarizing discussions between advocates of universal medicare expansion and advocates of restriction have been longstanding yet significant changes to how the covered basket of services is defined haven't occurred.2 A clear definition of medical necessity should be transparently created while considering clinical, economic, equity and ethical factors.3 Such a definition would encourage consistency in the provision of healthcare services across the country. Despite the rational goals of health policies, they are based on a culmination of choices that are influenced by changing political climates, current evidence, and policymakers.4 When making decisions about Canadian health policy, the series of possible future actions must be identified and analyzed to consider whether the benefits and costs of the choices are sufficiently justified.5 The issues discussed in this paper highlight the need for transparent and evidence-based frameworks when defining medical necessity. The Capstone undertakes a comparative analysis of how healthcare systems define medical necessity to understand the argument for health reform and defining the basket of medically necessary services. Reported recommendations include transparently defining the basket of medical services every 3-5 years, implementing the systematic use of health technology assessments, creation of one institute or agency to carry out all assessments of medical technologies to apply consistent assessment standards, and creation of an evidence-based delisting process for the provinces.