Review of Medical Necessity of Tests and Procedures
A decision as to whether something is or isn't necessary depends a whole lot on who's doing the deciding. A new opera business firm downtown? "Yes," says the music-loving arts community. "No," says the cash-strapped city quango. A new xc-inch television? "Yes," says the sports-mad husband. "No," says the level-headed wife.
In health intendance, opinions almost whether a particular service, test or procedure is "medically necessary" — and therefore covered past provincial health plans — can also vary widely. Equally divisive, in some quarters, are opinions about who should exist involved in making that decision.
"Medical necessity should be determined between the patient and the wellness care provider," says Dr. Douglas Mark, president of the Coalition of Family Physicians and Specialists of Ontario. "It should not exist the government making that decision."
According to Marker, the Ontario government is virtually to start "micromanaging" health intendance in the province. The government will now decide if certain services, such equally providing an MRI (magnetic resonance imaging) for low back pain, are really necessary and worthy of reimbursement through public funds. Marking claims this could eventually touch many fields of medicine, including cardiology, neurology, anesthesiology and ophthalmology.
"Some nameless, faceless bureaucrat in the government will decide who is or is not eligible for coverage for these X-rays, CT [computed tomography], and MRI scans. Some other example is mammograms," Mark stated in a press release (www.cofps.ca/2012/05/31/ontario-is-now-micromanaging-your-health-care). "Ultimately, information technology volition be our patients who will have to pay for these tests themselves with their health or even their lives, despite having already paid for wellness care through taxes and the additional healthcare levy."
In response to government plans to revise the process for determining what's medically necessary, the coalition has issued a "call to arms" asking doctors to send an "Ontario Medically Necessary Authorisation Requestion Form" to the province (www.cofps.ca/wp-content/uploads/2012/05/Medically-Necessary-Authority-Requisition-Form1.pdf). It states that a patient is "waiting in role/clinic/hospital for your immediate reply" regarding his eligibility for at to the lowest degree i of a number of tests, including electrocardiogram, mammogram, ocular ultrasound, cataract surgery sedation, x-ray of the lumbar spine and electroencephalogram.
Ontario doctors will no longer be reimbursed for magnetic resonance imaging scans for patients with low back pain if the government deems them unnecessary.
Image courtesy of © 2012 Thinkstock
"It'due south ludicrous. They're the ones now making decisions, from the top down," says Mark. "Information technology's completely backwards."
The government takes issue with that proposition. The betoken of the increased scrutiny is non to undermine physicians, simply rather to base of operations spending decisions on prove instead of the judgment of physicians solitary, says Deb Matthews, Ontario'south Minister of Wellness and Long-Term Intendance.
The government will rely on expert committees — comprising physicians, academics and other experts — to review scientific literature and determine when, and for whom, a test or procedure is really necessary. "We want people to get the care they need, simply we don't desire people to become through unnecessary tests and we don't want to pay for it," says Matthews. "I actually believe doctors desire to practise what'southward right for patients and for the organisation, and some might interpret this equally a claiming to their autonomy, but we have to exercise what's right for patients and what's right for the health care arrangement."
Bear witness suggests, for case, that physicians are far more than probable to order a exam if they own the machine needed to perform it, notes Matthews. There is as well a tendency among some doctors to order expensive tests prematurely. "We exercise know that some physicians were sending people with lower back pain for MRIs before doing annihilation else," says Matthews.
Academics who have studied processes for determining what is medically necessary tend to agree that clinicians shouldn't be the simply ones involved. Though medical expertise is of form required, the reality is that coin comes into play as well. Every public dollar spent on health care, later on all, is a dollar that can't exist spent to provide other types of services to citizens. And nobody expects doctors to make decisions about patient care based on how it will impact, say, teachers' salaries.
"At that place really is a office for people other than doctors in the process," says Marking Stabile, director of the School of Public Policy and Governance and professor of economics and public policy at the Rotman School of Management of the University of Toronto in Ontario.
Efforts to contain costs don't necessarily detract from the quality of health intendance, Stabile says. In fact, more efficient care can sometimes be amend care, even if physicians are reluctant to accept outside influence on how their practices should be run.
"Everybody would prefer to have nobody interfere with them, just at that place is some evidence, a lot of it from the United States, that when doctors are shown they tin can do a job amend by making some adjustments, in the long run they are happier," says Stabile.
According to some observers, bringing a wider range of experts into the mix is long overdue. "Doctors accept had the reins completely on deciding what is medically necessary and what is non, and that is increasingly going to have to come up under scrutiny," says Colleen Alluvion, a constabulary professor at the University of Toronto and a Canada Enquiry Chair in Health Police and Policy. "It's beholden on governments, who are spending public money, to take a await. … The regime plainly has to be involved in the sense that they gear up the budgets. Who else is going to stand for the public interest if not them?"
Others who might be able to provide valuable input to the process include ethicists, scientists, public policy experts and philosophers, says Flood. Members of the public should likewise take a voice, though questions remain about how and when they should be involved.
"At what point, given the historical and political complexities inherent in medicare, could (and should) the public be involved?" Flood and colleagues have asked (www.police.utoronto.ca/sites/default/files/health_basket/docs/working5_inandout.pdf). "What role could public values accept in determining what services are publicly funded and which are left to the private sector?"
Whoever is involved, information technology is important that the process non just be a bureaucratic exercise in saving money, says Flood. It must exist a off-white, reasonable process based on evidence. Most frequently, a decision regarding a particular test or procedure is not about whether it should exist publicly funded — full cease — merely rather almost who actually needs it and when is information technology necessary.
"We take to do this sort of thing to manage the health arrangement," says Flood. "Private doctors might not like having their decisions scrutinized, but why not? If you are making adept decisions, why would you care?"
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3494349/
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