1. Plaats | datum Choices in health decision-making Coverage in the Netherlands Bert Boer, MD, PhD Health Care Insurance Board (CVZ) Rotterdam, November 2010

2. 1 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. 2 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?

4. 3 1.Coverage in the Netherlands (system, principles:)  Mandatory insurance for all  Mandatory acceptance for insurance companies  Public definition of the package of benefits

5. 4 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. 5 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. 6 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. 7 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. 8 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. 9 AdviceKey criterion Combined life-style intervention effectiveness Contraceptiondomain Devices for walking assistance necessity Dentistry for age 18-22necessity IVFdomain Acetylcysteineffectiveness Oxycodineffectiveness Smoking cessationnecessity Dietary productsnecessity TNF-alpha blockerseffectiveness

11. 10 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

12. 11 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. 12 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. 13 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. 14 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. Plaats | datum Choices in health decision-making Coverage in the Netherlands Bert Boer, MD, PhD Health Care Insurance Board (CVZ) Rotterdam, November 2010