plaats | datum choices in health decision-making coverage in the netherlands bert boer, md, phd...
TRANSCRIPT
Plaats | datum
Choices in health decision-makingCoverage in the Netherlands
Bert Boer, MD, PhD Health Care Insurance Board (CVZ)
Rotterdam, November 2010
2
Key Message
Times are changing for HTA
The context (policy, politics) of HTA is not (anymore?) as was assumed
HTA as being intrinsic receiver oriented, has to be responsive to the apparently changing contextual values
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Choices in coverage
1. Coverage in the Netherlands: system, principles
2. Recent experiences in managing the package of benefits
3. Four principles for coverage: applicable, relevant?
4. Assessment, societal appraisal, political decisions
5. Conclusions
6. During drinks: HTA, how to proceed?
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1. Coverage in the Netherlands(system, principles:)
Mandatory insurance for all
Mandatory acceptance for insurance companies
Public definition of the package of benefits
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Mgt. of the package of benefits(tasks of CVZ:)
Explaining what’s in it and what’s not, and why
Statements on insurance status (application of general criteria to specific technologies)
Advice on inclusions / exclusions
Advice in disputes
Advice on coverage system: criteria, structure
Monitoring utilization (spec. topics, i.e. drugs)
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Mgt. of the package of benefits:four basic principles
Necessity of health care (severity, burden if illness) of health care coverage (predictability, affordability, …)
Effectiveness
Cost-effectiveness
Feasibility
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2. Recent experiencesIntroduction of the societal appraisal committee (ACP) implied introduction of appraisal
Appraisal or assessment of the four principles?Necessity
Effectiveness
Cost-effectiveness
Feasibility
Assessment: 1a, 2, 3, and domain (a preceding general consideration)
Appraisal: 1b, 4
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2. Recent experiences (#2)Shift in the traditional sequence “assessment/appraisal”
Examples:
Scoping of relevant aspects for assessment
Choice for relevant effects to be assessed depends on social values
Repeated assessment (and - decisions) are increasingly needed
Lack of evidence about effectiveness stops the game
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What was the decisive criterion?
Review of the last 10 CVZ-advices on in- or exclusion of services
Which of the four basic principles appeared to be decisive?
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Advice Key criterionCombined life-style intervention effectiveness
Contraception domain
Devices for walking assistance necessity
Dentistry for age 18-22 necessity
IVF domain
Acetylcystein effectiveness
Oxycodin effectiveness
Smoking cessation necessity
Dietary products necessity
TNF-alpha blockers effectiveness
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3. Conclusions about principles
1. Necessity has to be split
2. Although we strive for integral application of the principles, lack of (proof of) effectiveness is the end of the story (no other aspects assessed)
3. Cost-effectiveness and feasibility appeared to be non-decisive
4. In two cases we needed the preceding question about the limits of the health domain
Former examples dyslexia; cosmetic surgery Legal basis for this question in the Health Insurance Act
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4. Assessment, Appraisal, CVZ advice, political decisions
In “95 %” political decisions follow the CVZ advice
Delicate issues, to be evaluated:
Between advisory committee (ACP) and CVZ-board: Smoking cessation, contraception
Between CVZ and MoH: contraception
Within “politics” (MoH1/MoH2, MoH/parliament): walking assisting devices
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The role of politics
CVZ always acknowledged the possibility of different weighing of arguments by politicians
But:
We attempt to prevent “new” arguments in the political debate
What lessons to be learned from recent politics?
Should we change the principles?
Only if politics appears to systematically use other principles
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5. ConclusionsThe classical HTA-sequence “research - decision” doesn’t fit anymore
Cost-effectiveness is not very often decisive
We should reconsider the role (sequence, weight) of the four assessment criteria and the relationship with appraisal and decision making
We need “methodology” for the societal appraisal
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Drinks…HTA is multidisciplinary research for policy decisions
If so, then:
HTA has to develop from (only) health economics into the review of all relevant factsAssessment doesn’t always precede appraisal; in many cases it’s the other way aroundHTA has to be enriched by criteria and methods for societal appraisal
Plaats | datum
Choices in health decision-makingCoverage in the Netherlands
Bert Boer, MD, PhD Health Care Insurance Board (CVZ)
Rotterdam, November 2010