Dif­fer­ence be­tween ‘need’ and ‘want’

What should be cov­ered by our pub­licly funded health-care sys­tem?

The Guardian (Charlottetown) - - OPINION - BY BRIAN W. ROTENBERG

All across Canada pro­vin­cial gov­ern­ments are grap­pling with ever grow­ing health­care de­mands in the face of shrink­ing re­sources. Our en­vi­able pub­licly funded health sys­tem is now well into a down­ward spiral of un­en­vi­able dis­re­pair. As pa­tients are be­com­ing more knowl­edge­able about their own care, and as doc­tors de­velop a wider ar­ray of op­tions avail­able to treat dis­eases, the costs are in­creas­ing.

The truth is, we can’t have it all. Both the physicians who de­liver care and the pa­tients who re­ceive it need to start con­sid­er­ing the con­cept of lim­ited re­sources in our pub­licly funded health­care sys­tem.

One of the main tenets of the Canada Health Act is that med­i­cally nec­es­sary care should be in­sured by pub­lic funds and that all re­lated hos­pi­tal or physi­cian care should be paid for by the pub­lic sys­tem. This is the soul of the cher­ished no­tion of “free” health­care that most Cana­di­ans hold so dearly.

But the tricky thing is that the Canada Health Act does not ac­tu­ally de­fine what con­sti­tutes “med­i­cally nec­es­sary care.” This is left up to the in­di­vid­ual health providers to de­ter­mine, on a case-by-case ba­sis.

At first glance it might seem easy to dis­tin­guish “med­i­cally nec­es­sary” care from op­tional care. If a pa­tient is sick, then the treat­ment needed to fix the prob­lem is in­tu­itively con­sid­ered nec­es­sary — the idea be­ing that med­i­cal needs dic­tate what will be pro­vided by the pub­lic sys­tem.

And in some cir­cum­stances, de­ter­min­ing what is “med­i­cally nec­es­sary” is easy. Both pa­tients and doc­tors could likely agree that if you have can­cer, it needs med­i­cal treat­ment. If you have frac­tures from a car ac­ci­dent, they need to be fixed.

Like­wise there are many other ex­am­ples that most of us could agree fall into ‘op­tional’ care, such as laser eye surgery to re­move the need for glasses or cos­metic fa­cial surgery – wants, not needs, that don’t merit pub­lic fund­ing.

In be­tween th­ese ex­am­ples, though, is a wide gray area where dis­tin­guish­ing need from want is not nearly so clear. Is fix­ing an an­noy­ing nasal block­age a need or a want? Is get­ting arthroscopy for a sore knee a need or a want? How about a pa­tient who wants blood tests that aren’t med­i­cally in­di­cated, but they are just cu­ri­ous?

Non-es­sen­tial care is by no means lim­ited to pa­tient de­mand. There also ex­ists a vast ar­ray of low-qual­ity or low-im­pact health in­ter­ven­tions ini­ti­ated by doc­tors — and pub­licly funded. Many of th­ese in­ter­ven­tions are not sup­ported by ev­i­dence. That blood test or chest x-ray your physi­cian or­dered for you be­fore your elec­tive op­er­a­tion? Very pos­si­bly un­nec­es­sary. The CT scan you had for pain in your lower back? The ev­i­dence says it will not im­prove your out­comes. The an­tibi­otics you were pre­scribed for a per­sis­tent virus? Un­nec­es­sary and they won’t work any­way.

Tests and treat­ments like th­ese ex­am­ples, and oth­ers, are not med­i­cally nec­es­sary and they are also costly to the strug­gling health­care sys­tem. In fact, un­nec­es­sary tests can ex­pose pa­tients to harm be­cause of false-pos­i­tive rates. The “Choos­ing Wisely Canada” ini­tia­tive spear­headed by the Cana­dian Med­i­cal As­so­ci­a­tion is just be­gin­ning to ex­plore the mas­sive scope of un­nec­es­sary care and the im­pact it has on pa­tients and the health sys­tem.

Are doc­tors too of­ten of­fer­ing to use pub­lic funds to in­ves­ti­gate or treat prob­lems that are wants ver­sus needs and not ac­tu­ally med­i­cally nec­es­sary? Are pa­tients los­ing sight of the fact that no prov­ince has the funds to pro­vide all care for all peo­ple all the time?

Our con­tem­po­rary free-for-all style of health­care, a chal­lenge on both sides of the med­i­cal con­sul­ta­tion room, is to­tally un­sus­tain­able on the pub­lic purse.

Doc­tors need to start openly and di­rectly con­sid­er­ing the con­cept of med­i­cal ne­ces­sity when talk­ing with pa­tients about tests or pro­ce­dures. Pa­tients, in turn, need to keep in mind that their health­care is not “free,” and that many of their health-re­lated com­plaints likely rep­re­sent wants, rather than needs.

Work­ing to­gether we can sal­vage what is left of pub­lic health­care in this coun­try, but only if both groups promptly adopt a more re­al­is­tic at­ti­tude to­ward med­i­cal ne­ces­sity.

Brian Rotenberg is an ex­pert ad­vi­sor with

Ev­i­denceNet­work.ca and an As­so­ciate Pro­fes­sor in the Depart­ment of Oto­laryn­gol­ogy – Head & Neck Surgery at Western Univer­sity, Lon­don, On­tario.

Dr. Brian Rotenberg

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