Breedte geneesmiddelenpakket - Index of

principle of need and solidarity implies that resources should be concentrated where the
needs are biggest, and that special attention should be given to the needs of the
weakest.[2, 6] In this way priority setting is made relative to “need”.
The last example in this review of the relativity of necessary care is the Oregon case.
Initially, the proposed list of treatments covered by insurance were based on clinicaleffectiveness
and cost-effectiveness. However, the resulting list of priorities was
perceived as quite unfair by the public. For instance, there was general disagreement
about the ranking of the treatment of a headache above the treatment of AIDS. The
initial list was revised on the basis of the “necessity of the intervention”. To account for
the necessity of a treatment, a set of categories was developed that depicted varying
types or degrees of expected health benefits. The categories were ranked using three
criteria: the value to the society, the value to an individual at risk of needing the service
and the essentiality to basic health care.[7] The remaining 17 categories were
subsequently divided into three groups.[2, 6, 8] The categories in turn, were divided into
three groups; essential services, very important services and services that are valuable
to certain individuals.[8]
Oregon’s final priority list was generated primarily by reference to category assignment.
Moreover, services were arranged within categories (prior to hand-rearranging)
according to the net benefit component of the cost-effectiveness formula. Note that the
criterion ‘necessity’ is used here as a relative criterion, and that it interacts with (cost)effectiveness.
Countries like Canada, New Zealand, Australia and the UK are setting priorities without
defined use of the criterion “necessary care”. In these countries, priority setting is mostly
based upon the criteria ‘equal access’ and ‘cost-effectiveness’.[9, 10] In the UK the
government does not make the choices but gives a fixed budget to the providers, the
health authorities. These health authorities determine which interventions are eligible for
reimbursement, without the explicit use of the criterion “necessity”. Examination of the
list of excluded services shows us that ‘necessity’ seems to play an implicit role.
Compared to the other countries, the UK bases necessity more on medical arguments.
Some interventions are not seen as necessary care because of the lack of medical
need.[11] This limited use of the criterion necessity is probably a result of the original
goal of the NHS to deliver a ‘comprehensive’ service. Additionally, in the UK financial
pressure is increasing and some suggest that the concept of a comprehensive service
has outlived its usefulness.[12] In the UK, the National Institute for Clinical Excellence
(NICE) has been charged with providing the NHS with clear advice about the appraisal
of new technologies. Other functions are the development of practical guidelines and
encouraging quality improvement. NICE is expected to give advice on the clinical
effectiveness and cost-effectiveness of both new and already existing health
technologies, including drugs.[13] In this way, NICE can be seen as an instrument for
rationing health care. But, the process is still far from transparent and it is important to
realise that political arguments are as important as evidence in the final decision.
© iMTA, Rotterdam april 2001 78