The Role of Medical Necessity in Canadian Health Policy. Four Meanings and... a Funeral?

C Charles, J Lomas, M Giacomini, V Bhatia and V Vincent

No 1996-18, Centre for Health Economics and Policy Analysis Working Paper Series from Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Canada

Abstract: This paper explores the emergence, evolution and dominance of four predominant mean-ings of the concept of medical necessity that have been used in past and current health policy debates about the appropriate level of service coverage under Canada’s health insurance pro-gram. Data for this study derived from a historical analysis of reports and policy or position papers prepared by provincial governments and national health care associations in response to federal legislative and policy reviews of Canada’s evolving health insurance program from 1957 to 1984. More current reports focussing explicitly on medical necessity were also reviewed. Our analysis revealed four predominant meanings of medical necessity. These are: “what doctors and hospitals do”, “the maximum we can afford”, “what is scientifically justified”, and “what is consistently funded across all provinces”. The paper explores how each of these meanings has evolved and been used by different stakeholder associations and governments to achieve different policy objectives at different points in time. Limitations of using the concept of medical necessity as a policy tool to determine health service coverage under public programs are also discussed.

Date: 1996
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