A Physician’s View about Medical Necessity

“Doc, do I really NEED this medication?”

In my practice, I seem to hear this question (or something like it) on a daily basis.  The question is not always about a medication, maybe it’s about a lab test or a scan, a procedure, or even a surgery.  But I still hear similar questions quite often.  Granted, my practice is quite a different type of practice than most, but more about this is a minute.

The answer to the question really speaks to the heart of what “medical necessity” actually means.  Is medical necessity only defined as something that will attempt to save the patient’s life or limb? What about protecting a major organ from future failure or damage? Is the treatment a means of preventing something unexpected or life-threatening from happening a month or a year from now? Maybe 10 years or 30 years from now???

In my practice most of my patients do not have illnesses that put their lives at significant risk.  Most of the focus is on trying to improve a patient’s symptoms or quality of life.  Patients in my practice usually have gastroesophageal reflux disease (GERD), with symptoms such as heartburn, chronic cough, throat clearing, etc., that make their lives miserable.  Even still I get asked if they really “need” their medications.  I struggle to give a quick response to this question.

Most people would probably accept the prevention of an untimely death as “necessity” (even though we could take a fatalistic view by saying that nobody “needs” anything because our fate is already predetermined.  I doubt most of us would accept that).  But ultimately it comes down to a choice: you could argue that no one “needs” their life-saving medications if they choose to accept the risks of NOT taking them (i.e., an earlier death).  This IS an option.  Therefore necessity is relative.

A similar argument could be made for diseases like hypertension or diabetes.  No one NEEDS their treatment.  All they really NEED is to consider the benefits that their treatment might provide, and decide if these benefits are important to them and their values.

In my patients’ situations, necessity is even more nebulous. They have come to me for help with a problem that is usually not life-threatening, not organ-threatening, but is threatening their quality of life.  After my assessment, I suggest diagnostic tests and/or therapies.  Do they NEED to follow my suggestions?  In my mind, the answer is always a resounding NO.  In reality, I feel that this should always be the answer, irrespective of the medical condition.  But how do I tell a patient (and even worse, an insurance company) that they do not NEED to follow (or pay for) my suggestions?

Instead the discussion really should center around a decision, and this is the crux of the matter.  Patients must consider what could happen if they don’t follow my suggestions versus would could happen if they do (N.B. I didn’t say what WILL happen…!!!). NEED should be measured relative to another option, or at least a chance at another option.  In sepsis, do you need antibiotics? No, but using them will hopefully lead to a better chance at averting death.  In diabetes, do you need to avoid candy? No, but doing so will help lower the risk of long-term complications.  In uncomplicated GERD, do I need my medication? No, but taking it increases the likelihood your symptoms will stay controlled.

When it comes down to it, instead of telling patients that they NEED something, I like to put the NEED in perspective for them.  Then let them make the decision.

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About Ryan Madanick, MD

I am a gastroenterologist at the University of North Carolina School of Medicine, as well as the Program Director for the GI & Hepatology Fellowship Program. I specialize in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD. I can be followed on Twitter: @RyanMadanickMD (he/him)
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2 Responses to A Physician’s View about Medical Necessity

  1. Melissa Travis says:

    I like to ask and hear the answer – “what are the implications of x” that way I hear multiple views of specific treatments or tests. That way it isn’t a NEED but more of discussion of where are YOU coming from and where are you seeing me. And meshing that with my ability to follow through.

    If I am supposed to be compliant on expensive, or uncomfortable medications – it will be more difficult UNLESS I know the long (and shorterm) implications of both taking them and not taking them. And I might also recognize that dietary changes, losing weight, exercise, or other perhaps more difficult longterm committments MIGHT enhance my health (like GERD) but I’ll have to get there. And Rome wasn’t built in a day…

    YES to get to MY GOALS these are necessary FOR NOW. And if my physician understands what my goals are we’ll get there together.

    Then again – I’m sort of a fan of benign neglect. So there’s that.

    Nice post.
    -M

  2. Pingback: Are we really training learners to manage diseases? | Gut Check Blog

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