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Although the ratios are playing a part, the threshold is not an absolute decision rule. The PBAC Guidelines regarding economic evaluations refer to a number of other factors that the committee considers to be also relevant, which include for example the lack or inadequacy of alternative treatments currently available, the perceived need in the community and the seriousness of the intended indication. So, the listing process is not without an element of egalitarism, as, in making listing recommendations, the PBAC adopts a societal perspective and takes into account issues such as equity, equal access and the need for a drug.[15] In Australia, economic efficiency is important for making reimbursement decisions, but also other implicit arguments are playing part in the decision making process. Unfortunately, there is little literature available in the public domain on the reasoning behind these decisions on listing. In conclusion, it seems that a successful use of necessary care as an explicit criterion is related to a relative use. In the countries that have tried to use the criterion necessary care in an absolute way the criterion is either not used (The Netherlands) or merely ad hoc (Germany). On the other hand, Belgium, France, Norway, and Oregon have used the criterion to set priorities or to set the level of co-payment or the level of public funding. We do not have the data to establish the effects of these operationalization. However, literature suggests, for instance, that a higher level of co-payments results in a decreased use of medical care and in lower health care costs. One of the most important conclusions of the RAND-experiment, a large-scale investigation of the effects of own payments on the use of health care in the United States, is that own payments end in a decreased use of medical care and in lower health care costs.[16] This conclusion is consistent with Dutch studies in this field.[17, 18] Co-payment and reimbursement Except for The Netherlands, cost sharing is one of the most commonly deployed costcontainment measures in most countries. The usual purpose of introducing co-payments is to control the demand for health care as well as to achieve direct savings by cutting the governments share of the cost. Two main forms of co-payment have been implemented, namely a co-payment for a drug and the use of deductibles. A deductible is a fixed amount of the costs that will be borne by the patient, with the surplus amount covered by the government or insurer. © iMTA, Rotterdam april 2001 80
Figure 2. User charges as source of health care finance in the EU in the early 1990s as percentages of total expenditure (Mossialos et al, 1999) User charges (including direct payments) EU Member State Figure 2 shows that the percentage of the user charges as a source of the health care finance is relatively low in The Netherlands, both for the user charges for health care interventions and for pharmaceuticals. Regarding co-payments in health service, The Netherlands finish second to last. In comparison to neighbouring countries, like Belgium and France, the Dutch user charges are approximately half.[19] Because of differences in price levels and reimbursement systems, one has to be careful with comparison of copayment levels. The percentages of user charges for pharmaceutical expenditures (table 3) seem quite comparable to the percentages given in the above figure. This does not apply to the UK, because there the percentage of co-payments for pharmaceuticals (24%) is much higher than the overall percentage of the user charge (3%). The percentage of co-payments in The Netherlands (8%) for pharmaceuticals is again much lower than in Belgium (29%) and France (34%).[20] Table 3. General methods of constraining pharmaceutical expenditures (Abel-Smith, 1994) Country Patient co-payment system % met by the patient Belgium 0/25/50/60/75/85/100% of price plus flat rate 29 Germany Flat rate depending on package size 7 Denmark 0/25/50/100% of price 47 Spain 0/40 % of price 32 France 0/40/65/100% of price 34 Greece 0/10/25% of price 25 Ireland 0 or up to IR90 per quarter n.a. Italy Flat rate plus 40/50% of price 18 Luxembourg 0/20% of price n.a. Netherlands Flat rate 8 Portugal 0/40/70% of price 23 UK Flat rate 24 The results show that almost all countries in our analysis use co-payment systems to control pharmaceutical expenditures. In most countries the patient has to pay a certain amount extra even for reimbursed medicines, but this proportion varies per country. The different ways countries decide on the level of co-payments in the pharmaceutical sector can be divided into three categories: 1) the percentage of co-payment is based on © iMTA, Rotterdam april 2001 81
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Rapport Breedte geneesmiddelenpakke
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Samenvatting Het rapport 'Breedte g
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1. Inleiding Achtergrond Verzoek mi
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vormt voor de huidige beoordelingss
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Advies WRR Generieke beoordelingen
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Eigen rekening en verantwoording Be
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Belangrijkste conclusies iMTA uitma
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3. Toetsing breedte geneesmiddelenp
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Kwantificering therapeutische waard
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Eén geneesmiddel: diverse indicati
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Wetgeving huidig verstrekkingensyst
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4. Conclusies en aanbevelingen 1) H
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9) De mogelijkheden om het criteriu
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Referenties Begeleidingscommissie U
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Colofon Auteurs: Mw. drs. E.A. Stol
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Samenvatting Deze bijlage is een ve
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weten: 1) bij luxe geneeskunde (IVF
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1 Inleiding 1.1 Probleemstelling Op
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De criteria effectiviteit en doelma
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geneesmiddelen werden uitgesloten v
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Het onderzoek naar de vraag hoe uit
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nadere invulling van de criteria en
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Van de twee betekenissen voor noodz
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2.2 Noodzakelijkheid als relatief c
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het mogelijk om nu met kwantitatiev
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Dat de kwaliteit van leven gewichte
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moeten spelen in de prioritering? W
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Aansluitend wordt in stap 3 een ber
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Page 65 and 66: 3 Eigen rekening en verantwoording
Page 67 and 68: van zorg moeilijk bespreekbaar. Het
Page 69 and 70: De vraag of een verstrekking voor e
Page 71 and 72: Rokers met een hoog cholesterol heb
Page 73 and 74: 4 Is er een rol voor het lifestyle
Page 75 and 76: 5 Het iMTA model Dit hoofdstuk besc
Page 77 and 78: Het kan worden opgemerkt dat het vo
Page 79 and 80: per QALY geprefereerd boven scenari
Page 81 and 82: huidige besluitvormingsprocedure ge
Page 83 and 84: onderdeel zijn van het doelmatighei
Page 85 and 86: De validiteit van onderzoeksresulta
Page 87 and 88: Neeling, 2000; Berg, in press). Van
Page 89 and 90: waarom het vermijden van inkomensef
Page 91 and 92: onderzoek start 1 juli 2001 en naar
Page 93 and 94: Literatuurlijst Andersson F, Lyttke
Page 95 and 96: Stolk EA, Brouwer WBF, Busschbach J
Page 97 and 98: Bijlage 1 Historisch perspectief In
Page 99 and 100: Maar omdat de grens van noodzakelij
Page 101 and 102: verschillende normatieve keuzen wor
Page 103 and 104: Dunning geïntroduceerd is, waarbij
Page 105 and 106: daarom ook voor de hand om de conse
Page 107 and 108: while others emphasise the need of
Page 109 and 110: Table 2. Example: reimbursement cat
Page 111: In Australia the Pharmaceutical ben
Page 115 and 116: which are not? In this way, Germany
Page 117 and 118: 17. Meer, J.v.d., Equal care equal
Page 119 and 120: Voorbeeld 2 Dit voorbeeld beschrijf
Page 121 and 122: Bijlage 4 Wegingsfactoren voor ziek
Page 123 and 124: Symptomatic non-fulminant acute hep
Page 125 and 126: Breast cancer, disseminated Interme
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