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Evidence-Based Health Care Policy in Reimbursement Decisions: Lessons from a Series of Six Equivocal Case-Studies

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  • Pieter Van Herck
  • Lieven Annemans
  • Walter Sermeus
  • Dirk Ramaekers

Abstract

Context: 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. Methods: 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. Findings: 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. Conclusions: ‘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’.

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  • Pieter Van Herck & Lieven Annemans & Walter Sermeus & Dirk Ramaekers, 2013. "Evidence-Based Health Care Policy in Reimbursement Decisions: Lessons from a Series of Six Equivocal Case-Studies," PLOS ONE, Public Library of Science, vol. 8(10), pages 1-10, October.
  • Handle: RePEc:plo:pone00:0078662
    DOI: 10.1371/journal.pone.0078662
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    Cited by:

    1. Van den Heede, Koen & Quentin, Wilm & Dubois, Cécile & Devriese, Stephan & Van de Voorde, Carine, 2017. "The 2016 proposal for the reorganisation of urgent care provision in Belgium: A political struggle to co-locate primary care providers and emergency departments," Health Policy, Elsevier, vol. 121(4), pages 339-345.
    2. Irina Odnoletkova & Dirk Ramaekers & Frank Nobels & Geert Goderis & Bert Aertgeerts & Lieven Annemans, 2016. "Delivering Diabetes Education through Nurse-Led Telecoaching. Cost-Effectiveness Analysis," PLOS ONE, Public Library of Science, vol. 11(10), pages 1-18, October.

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