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Evolving Health Decision-making in the Netherlands: Insights from Coverage Choices

Explore the changing landscape of health decision-making and insurance coverage in the Netherlands, including principles, recent experiences, and key criteria influencing policy and political decisions.

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Evolving Health Decision-making in the Netherlands: Insights from Coverage Choices

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  1. 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

  3. Choices in coverage • Coverage in the Netherlands: system, principles • Recent experiences in managing the package of benefits • Four principles for coverage: applicable, relevant? • Assessment, societal appraisal, political decisions • Conclusions • During drinks: HTA, how to proceed?

  4. Coverage in the Netherlands(system, principles:) • Mandatory insurance for all • Mandatory acceptance for insurance companies • Public definition of the package of benefits

  5. 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)

  6. 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

  7. 2. Recent experiences • Introduction 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

  8. 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

  9. 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?

  10. Advice Key criterion • Combined life-style intervention effectiveness • Contraceptiondomain • Devices for walking assistance necessity • Dentistry for age 18-22 necessity • IVFdomain • Acetylcystein effectiveness • Oxycodin effectiveness • Smoking cessation necessity • Dietary products necessity • TNF-alpha blockers effectiveness

  11. 3. Conclusions about principles • Necessity has to be split • Although we strive for integral application of the principles, lack of (proof of) effectiveness is the end of the story (no other aspects assessed) • Cost-effectiveness and feasibility appeared to be non-decisive • 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

  12. 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

  13. 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

  14. 5. Conclusions • The 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

  15. 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 facts • Assessment doesn’t always precede appraisal; in many cases it’s the other way around • HTA has to be enriched by criteria and methods for societal appraisal

  16. Choices in health decision-makingCoverage in the Netherlands Bert Boer, MD, PhD Health Care Insurance Board (CVZ) Rotterdam, November 2010

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