Plaats | datum

Choices in health decision-makingCoverage in the Netherlands

Bert Boer, MD, PhD Health Care Insurance Board (CVZ)

Rotterdam, November 2010

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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