Does Medical Necessity Depend on the Province You Live in?

Does Medical Necessity Depend on the Province You Live in?

< Back to Articles | Topics: Working for you | Contributors: Chris Cowper-Smith | This is a guest post from Mable Health
(Member since 2023) | Published: October 2, 2023

This is a guest post from Mable Health
(Member since 2023)

Canadians needing access to medical devices ranging from artificial limbs (i.e., prosthetics) to hearing aids often face a complex and expensive process to ensure they can live an accessible life. This is due to substantial variability across the provinces and territories in the definitions, regulations, and available funding for essential medical equipment.

The variability of medical device access across the country means Canadians living in one province can receive vastly different care than those living in another. For example, if you live in Nova Scotia, full coverage is possible for prosthetic limbs, but only if that care is provided through the Nova Scotia Rehab. By comparison, Ontario typically offers partial coverage while Alberta offers full coverage and New Brunswick offers nothing. Similar inter-provincial variability exists for other medical devices prescribed for by a physician, but that are delivered outside their office.

It’s time for us to ask why we accept so much variability of access to medical devices across the country. Under the Canada Health Act, all provinces must cover the cost of ‘essential healthcare services’, however the definition of medical necessity is left to the provinces for care that is prescribed for but offered outside a hospital setting. This means that the standard and quality of care received by Canadians varies, sometimes arbitrarily, depending on the province you live in.

Is a knee replacement more medically necessary than a prosthetic leg? Why does an amputee have to dip into their life savings for the ability to walk again while someone with knee arthritis doesn’t?

Depending on where they live, patients requiring a prosthetic device have three potential routes to access funding in Canada:

  1. Provincial healthcare funding
  2. Private insurance
  3. Charitable sources

Due to badly outdated fee schedules and a lack of clarity around what is covered (or not), securing that funding is often a complex process involving detailed applications, appeals, and negotiations around eligibility.

All of this leads to inefficiencies in care delivery and creates an environment where it’s common for clinicians and their teams to spend dozens hours attempting to obtain coverage for their patients. Wouldn’t we rather see them help more patients?

Why is this important?

  1. Patients are Suffering.
    An inability to walk is debilitating enough. A lack of adequate treatment leads to a wide range of secondary health complications ranging from congestive heart failure to metastatic cancer and stroke.

  2. The Economic Burden of Inadequate Care.
    The cost of secondary health complications increases at an exponential rate. In the case of diabetic foot ulcers, an appropriate orthotic device capable of offloading the ulcer and dramatically reducing the risk of amputation is approximately $1500-$2500. If appropriate care isn’t received and that patient requires amputation, the procedure will cost the health care system approximately $18,000. Costs continue to climb thereafter.

  3. Barriers to Accessing Health Care Innovation.
    The complexity of obtaining provincial coverage for new medical devices in Canada deters domestic and international manufacturers from bringing their products to market. Even home-grown medical device companies, often funded with millions in tax dollars, routinely skip commercializing their devices in Canada, choosing instead to pursue larger markets with simplified regulatory and reimbursement pathways.

What can we do to solve these challenges?

  1. Create a national standard:
    Set and enforce a national standard that aligns funding levels for medically necessary devices across the country.
  2. Establish legislation:
    Establish legislation that prohibits insurers from creating and selling policies with arbitrary caps on medically necessary devices.
  3. Simplify coverage:
    Streamline the application and approval process for new medical devices seeking coverage through Canada's public health care system.

It’s time to insist we take better care of persons with disability. Aligning funding and simplifying coverage across the country will provide better access, better efficiency, and reduce overall healthcare costs.

< Back to Articles | Topics: Working for you

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