MRG Principles and Policy Statements
MRG Policy Statement on the Definition of Insured Services.
Up to now, we have not had a clear definition of the insured health services
that provincial governments are mandated to provide
to the public. Legislation stipulates that these services
be comprehensive, but comprehensiveness is subject to wide
interpretation. The result is there is appreciable heterogeneity
in the services covered by the various provincial health plans.
Recently, observers of the Canadian
health care system have suggested that it is time to more
precisely define insured services. Sources of pressure have
included members of the legal community, and voices warning us that,
in the face of budget restraints, we can't maintain the current
level of public health care. The focus of the definition of insured
services is on "medical necessity" -- the notion being that
only medically necessary services should be covered.
Intuitively, precise definition
of insured services make some sense. Public values define
what is appropriate coverage, and we establish uniformity
across provinces. We reduce the burden on public spending
by eliminating inappropriate services from the domain of the
insured. Potentially, this allows us to continue with universal
coverage for the services that are really important. There are,
however, a number of major problems with this approach.
First, it equates comprehensive
coverage with medical necessity. The two are very different.
Many health services, including for instance dental care, are
necessary for maintenance of health, but well not be considered
"medically necessary". Limiting exposure to environmental pollutants
is necessary for maintenance of health, but is even farther from
some peoples' notion of medical necessity.
Second, even if one accepts the
limited scope of medical necessity, the process of considering
specific services makes evident the difficulties of defining
the correct range of insured benefits. While there are many
services about which one can raise questions on the basis of public
versus individual responsibility (tattoo removal, for instance),
one can almost invariably think of instances in which one would want
these services covered. While one can raise questions about the effectiveness
of services (intensive psychotherapy, for instance) considering
both the caring and curing functions of medicine gives one pause.
The MRG has found that discussions of the exact range of appropriate
insured services quickly show that satisfactory resolution is impossible.
This makes us question the need
for a precise definition of insured services. The Canadian
health care system worked well for 25 years without such a
definition. Provincial governments have maintained acceptable coverage,
and there are few, if any, gross violations of the principle of
comprehensiveness. Should there be such violations, the federal
government is in a position to withhold funds from the offending
provinces. So why the current debate?
The debate is a function of the
budgetary pressures on governments. The cost-cutters see
restricting the range of insured services as a way of trimming
the system. As it turns out, when one looks at what we will
save by de-insuring the controversial procedures, the amount
is trivial. To really reduce public expenditure would require
removing a wide range of services. We believe the push for a definition
of insured services is another feature of the systematic attempts
to undercut our universal public health care system.
With respect to definition of insured
services, the system isn't broken, and doesn't need to
be fixed. The solution to the problems of cost pressures on
the system include improving efficiency in health care, and revising
our priorities on the mix of public and private resource allocation
within our society. Canada's current rationing strategy, limiting
resource availability (hospital beds, high technology equipment,
the number of health care providers) and letting health care providers
work out the most efficient way of using the resources available,
continues to be the most appropriate.
Our answer to the precise definition
of necessary services is that we don't need such a definition.
If pressed further, we believe that we should not consider
only what is medically necessary, but rather the notion of comprehensive
care required to maintain and enhance health. Under this framework,
we would use the broadest definition of insurable services, including
areas on the border of health care that nevertheless have an important
impact on health. The health care community should, for instance,
be involved in ensuring optimal environmental standards. Our bottom
line is that the debate concerning what is necessary medical care
ultimately distracts us from dealing with the real issues in health
care delivery today.
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