Center for Health Services and Nursing Research, University of Leuven, Leuven, Belgium.
PLoS One. 2013 Oct 30;8(10):e78662. doi: 10.1371/journal.pone.0078662. eCollection 2013.
Health care technological evolution through new drugs, implants and other interventions is a key driver of healthcare spending. Policy makers are currently challenged to strengthen the evidence for and cost-effectiveness of reimbursement decisions, while not reducing the capacity for real innovations. This article examines six cases of reimbursement decision making at the national health insurance authority in Belgium, with outcomes that were contested from an evidence-based perspective in scientific or public media.
In depth interviews with key stakeholders based on the adapted framework of Davies allowed us to identify the relative impact of clinical and health economic evidence; experience, expertise & judgment; financial impact & resources; values, ideology & political beliefs; habit & tradition; lobbyists & pressure groups; pragmatics & contingencies; media attention; and adoption from other payers & countries.
Evidence was not the sole criterion on which reimbursement decisions were based. Across six equivocal cases numerous other criteria were perceived to influence reimbursement policy. These included other considerations that stakeholders deemed crucial in this area, such as taking into account the cost to the patient, and managing crisis scenarios. However, negative impacts were also reported, in the form of bypassing regular procedures unnecessarily, dominance of an opinion leader, using information selectively, and influential conflicts of interest.
'Evidence' and 'negotiation' are both essential inputs of reimbursement policy. Yet, purposely selected equivocal cases in Belgium provide a rich source to learn from and to improve the interaction between both. We formulated policy recommendations to reconcile the impact of all factors identified. A more systematic approach to reimburse new care may be one of many instruments to resolve the budgetary crisis in health care in other countries as well, by separating what is truly innovative and value for money from additional 'waste'.
新药、植入物和其他干预措施推动了医疗技术的发展，这是医疗保健支出的主要驱动因素。政策制定者目前面临的挑战是，既要加强证据，又要提高报销决策的成本效益，同时又不能降低真正创新的能力。本文以比利时国家健康保险管理局的六项报销决策为例，这些决策在科学或公共媒体上从基于证据的角度来看是有争议的。
根据 Davies 的改编框架，对主要利益相关者进行深入访谈，使我们能够确定临床和健康经济证据的相对影响；经验、专业知识和判断；财务影响和资源；价值观、意识形态和政治信仰；习惯和传统；游说团体和压力团体；实用主义和偶然性；媒体关注；以及来自其他付款人和国家的采用。
证据并不是报销决策的唯一依据。在六个有争议的案例中，许多其他标准被认为会影响报销政策。这些标准包括利益相关者认为在这一领域至关重要的其他考虑因素，如考虑到患者的成本，以及管理危机情况。然而，也报告了一些负面影响，如不必要地绕过常规程序、意见领袖的主导地位、选择性地使用信息以及有影响力的利益冲突。
“证据”和“谈判”都是报销政策的必要投入。然而，比利时有争议的案例研究为学习和改善两者之间的互动提供了丰富的素材。我们制定了政策建议，以协调所有确定因素的影响。在其他国家，通过将真正的创新和物有所值与额外的“浪费”区分开来，为新的医疗保健提供更系统的报销方法可能是解决医疗保健预算危机的众多手段之一。
