BS: Medical Necessity

Subject: BS: Medical Necessity
From: Janie
Date: 16 Aug 12 - 09:23 PM

Thinking about what constitutes "medical necessity" in the context of the current USA health care climate and debate. In the USA, traditionally, medical necessity has been defined as "I want it and can use it and a doctor says I can benefit from it." We don't have tight or clearly defined criteria for "medical necessity." As we move closer (I hope) toward universal health care, it is inevitable as well as reasonable that "medical necessity" be more clearly and uniformly defined, and that there be a reasonably cogent systemic method to prioritize "medical necessity." A system that offers more universal coverage is going to have to prioritize and in some instances limit publicly funded coverage more stringently than is currently the case with either private or public insurances and payor systems in the USA.

Wondering what those priorities look like in countries that do provide for universal health coverage. If anyone here works in the health care industry in a country that provides for universal health coverage or insurance, would be interested in pms from you about the strengths and weaknesses, as well and your personal experiences.

Subject: RE: BS: Medical Necessity
From: Janie
Date: 16 Aug 12 - 09:34 PM

Should have proof read better for content. Not just interested in the experiences and thoughts of providers, but also interested in the considered thoughts and experiences of recipients or consumer participants living and particiating in health care systems in countries that have some form of universal coverage.

Subject: RE: BS: Medical Necessity
From: GUEST,Eliza
Date: 17 Aug 12 - 03:30 AM

Here in UK we have the mis-named NICE system (National Institute for Health and Clinical Excellence), issuing guidelines as to which medications can be prescribed and which are either too expensive or deemed unsuitable for various reasons. I appreciate that in the NHS there is limited funding, and very expensive treatments mean other sufferers have to do with less. Also, (understandably) people who are dangerously ill see claims of wonder drugs and new treatments which they demand to be given. These are not always substantiated or fully tested and the NHS has a duty to monitor such 'breakthroughs' with circumspection. I believe there have been some cases pursued by patients where NICE guidelines have been overturned. But the budget won't stretch indefinitely, and one patient's expensive drugs mean another patient's being given short shrift. Very hard, especially for those with life-threatening diseases.