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Case-studies of displacement effects in Dutch hospital care

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Background: Under a constrained health care budget, cost-increasing technologies may displace funds from existing health services. However, it is unknown what services are displaced and how such displacement takes place in practice. The aim of our study was to investigate how the Dutch hospital sector has dealt with the introduction of cost-increasing health technologies, and to present evidence of the relative importance of three main options to deal with cost-increases in health care: increased spending, increased efficiency, or displacement of other services. Methods: We conducted six case-studies and interviewed 84 professionals with various roles and responsibilities (practitioners, heads of clinical department, board of directors, insurers, and others) to investigate how they experienced decision making in response to the cost pressure of cost-increasing health technologies. Transcripts were analyzed thematically in Atlas.ti on the basis of an item list. Results: Direct displacement of high-value care due to the introduction of new technologies was not observed; respondents primarily pointed to increased spending and efficiency measures to accommodate the introduction of the cost-increasing technologies. Respondents found it difficult to identify the opportunity costs; partly due to limited transparency in the internal allocation of funds within a hospital. Furthermore, respondents experienced the entry of new technologies and cost-containment as two parallel processes that are generally not causally linked: cost containment was experienced as a permanent issue to level costs and revenues, independent from entry of new technologies. Furthermore, the way of financing was found important in displacement in the Netherlands, especially as there is a separate budget for expensive drugs. This budget pressure was found to be reallocated horizontally across departments, whereas the budget pressure of other services is primarily reallocated vertically within departments or divisions. Respondents noted that hospitals have reacted to budget pressures primarily through a narrowing in the portfolio of their services, and a range of (other) efficiency measures. The board of directors is central in these processes, insurers are involved only to a limited extent. Conclusions: Our findings indicate that new technologies were generally accommodated by greater efficiency and increased spending, and that hospitals sought savings or efficiency measures in response to cumulative cost pressures rather than in response to single cost-increasing technologies.
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R E S E A R C H A R T I C L E Open Access
Case-studies of displacement effects in
Dutch hospital care
Joost Johan Godert Wammes
1*
, Geert Frederix
2
, Paulien Govaert
2
, Domino Determann
3
, Silvia Evers
4
,
Aggie Paulus
4
, Niek Stadhouders
1
, Patrick Jeurissen
1
, Wija Oortwijn
5
and Eddy M. M. Adang
5
Abstract
Background: Under a constrained health care budget, cost-increasing technologies may displace funds from
existing health services. However, it is unknown what services are displaced and how such displacement takes
place in practice. The aim of our study was to investigate how the Dutch hospital sector has dealt with the
introduction of cost-increasing health technologies, and to present evidence of the relative importance of three
main options to deal with cost-increases in health care: increased spending, increased efficiency, or displacement of
other services.
Methods: We conducted six case-studies and interviewed 84 professionals with various roles and responsibilities
(practitioners, heads of clinical department, board of directors, insurers, and others) to investigate how they
experienced decision making in response to the cost pressure of cost-increasing health technologies. Transcripts
were analyzed thematically in Atlas.ti on the basis of an item list.
Results: Direct displacement of high-value care due to the introduction of new technologies was not observed;
respondents primarily pointed to increased spending and efficiency measures to accommodate the introduction of
the cost-increasing technologies. Respondents found it difficult to identify the opportunity costs; partly due to
limited transparency in the internal allocation of funds within a hospital. Furthermore, respondents experienced the
entry of new technologies and cost-containment as two parallel processes that are generally not causally linked:
cost containment was experienced as a permanent issue to level costs and revenues, independent from entry of
new technologies. Furthermore, the way of financing was found important in displacement in the Netherlands,
especially as there is a separate budget for expensive drugs. This budget pressure was found to be reallocated
horizontally across departments, whereas the budget pressure of other services is primarily reallocated vertically
within departments or divisions. Respondents noted that hospitals have reacted to budget pressures primarily
through a narrowing in the portfolio of their services, and a range of (other) efficiency measures. The board of
directors is central in these processes, insurers are involved only to a limited extent.
Conclusions: Our findings indicate that new technologies were generally accommodated by greater efficiency and
increased spending, and that hospitals sought savings or efficiency measures in response to cumulative cost
pressures rather than in response to single cost-increasing technologies.
Keywords: Displacement, Opportunity cost, Priority setting, Rationing, Basic benefit package, Innovation, Health
technology assessment
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data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: jjgwammes@gmail.com
Wija Oortwijn and Eddy M. M. Adang contributed equally to this work.
1
Radboud university medical center, Scientific Center for Quality of
Healthcare, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
Full list of author information is available at the end of the article
Wammes et al. BMC Health Services Research (2020) 20:263
https://doi.org/10.1186/s12913-020-05086-9
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Background
In the Netherlands a broad agreement between stake-
holders in the healthcare sector has been agreed on,
among other things, maximum permitted budgetary
growth (1.3% in 2019, decreasing to 0% in 2022, exclud-
ing wage and price adjustment). Budget pressure is fur-
ther increased by the continuous introduction of cost-
increasing health technologies. Decision makers, both at
local and national levels, therefore need to make choices
about how to spend their resources. At the national
level, the Health Care Institute (ZINL) of the
Netherlands advises the Minister of Health (MOH) on
the contents of the basic benefit package. In 2016, ZINL
advised the MOH not to reimburse two expensive drugs
- Pertuzumab (Perjeta®) and Pembrolizumab (Keytruda®)
- unless their cost-effectiveness would be improved, and
budget impact would be less through price negotiations.
The main argument was that, in current economic cir-
cumstances, reimbursement of these drugs could require
displacement of more cost-effective services, resulting in
a net loss of health benefits at the population level [1].
Based on this advice, the Minister negotiated lower
prices with the manufacturers and decided that the
drugs would qualify for reimbursement until the end of
2019 [2]. These negotiated prices have not been revealed
in the public domain.
In England, Wales and Scotland, research into dis-
placement has mainly focused on estimating the cost per
QALY threshold [3,4]. Little is known however, about
displacement in practice, how displacement takes place
and what services are displaced to accommodate new
cost-increasing technologies. We know of few studies on
the introduction of cost-increasing technologies. One
Welsh study investigated how NHS commissioners ac-
commodated financial shocksoriginating from Tech-
nology Appraisals recommendations on the use of
new and existing medicines and treatments within the
NHS - issued by NICE. They found that the displace-
ment assumption(existing services are displaced to ac-
commodate cost-increasing technologies) generally did
not hold; and that financial shocks originating from
Technology Appraisals were generally accommodated by
greater efficiency and increased spending. In addition,
commissioners sought for savings or efficiency measures
in response to cumulative cost pressures from multiple
sources rather than in response to single Technology
Appraisals [5,6].
In the current research, we defined displacement as a
process, a total of decisions and resulting consequences
made in anticipation of, simultaneous with, or after the
introduction of a cost-increasing technology, with a net
negative health effect due to the introduction of the new
technology. This displacement process includes priority
setting at higher organisational levels and bedside
rationing at lower organisational levels. Insight in dis-
placement also requires exploration of the causality of
resource allocation ((how) does one decision leads to an-
other and the ultimate effects for individual patients).
We defined priority setting as resource allocation deci-
sions between different services, patient groups, or ele-
ments of care; whereas bedside rationing was interpreted
as the effects of such decisions on individual patients [7].
Priority setting in general has been researched for many
years, although relatively little attention has been paid to
the impact on individual patients.
The aim of our study was to investigate how Dutch
hospitals have dealt with the introduction of cost-
increasing health technologies, and to explore the rela-
tive importance of three main options to deal with in-
creasing cost pressure: increased spending, increased
efficiency, or displacement of other services. Specifically,
we aimed to analyse how stakeholders across all organ-
isational levels of hospital care experience displacement,
and how they understand or perceive resource allocation
or displacement decision making. Six case-studies of dif-
ferent cost-increasing hospital technologies were con-
ducted to understand similarities and differences
between cases, and to investigate the mechanisms of dis-
placement and how these relate to financial and organ-
isational structure.
Institutional background
In the Netherlands, nearly universal coverage for cura-
tive care is achieved through mandatory purchase of
statutory health insurance from private insurers. The
Health Insurance Act legally requires health insurers to
provide a comprehensive nationally set benefits package.
Decisions regarding the package rest with the Minister
of Health, who relies on advice from the National Health
Care Institute and its Healthcare Insurance Board [8,9].
Coverage of prescription drugs is described in positive
lists. Remaining service coverage is specified through an
open specification with a general (functional) description
of benefits, and restrictions are expressed in negative
lists [10]. The great majority of services enter the health
system without formal assessment through this open
specification.
The Health Care Institute uses four criteria to deter-
mine whether to reimburse a new health service: neces-
sity, effectiveness, cost-effectiveness, and feasibility for
implementation. Adoption of a technology is based on
an integral assessment along these criteria, although the
criteria are not used as knock-out criteria. The criteria
are continuously refined and improved, and especially
the cost-effectiveness criterion is debated. In 2006, the
RVZ (government advisory body) argued that treatments
with a cost-effectiveness ratio higher than 80.000/
QALY should not be included in the basic benefit
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package. The RVZ also stated that the acceptable costs
per QALY vary according to burden of disease and other
factors, such as rarity of the disease [11]. In reality, treat-
ments are rarely excluded from the basic package based
on unacceptablecost-effectiveness. In addition, besides
the appraisal criteria, several other factors have played a
role in defining the actual constituents of the basic bene-
fit package, including the desire to control costs and
public opinion [12].
The Dutch healthcare system is largely based on
the principles of managed competition with little cen-
tral planning. Health care purchasing is considered
the centerpiece of the system and is the main instru-
ment for stimulating efficiency. Insurers are supposed
to prudently purchase care for their enrollees. In real
life, insurers and hospitals mainly negotiate on vol-
umes and prices, while quality of care plays only a
minor role in these negotiations. In addition, insurers
may decide not to contract a provider (selective con-
tracting) but are required to offer adequate care for
their enrollees. The great majority of hospital care in
the Netherlands is reimbursed through payment prod-
ucts, similar to Diagnosis Related Groups (DRGs).
More than 70% of DRG-prices are freely negotiable,
the rest of the prices are regulated. A small part of
hospital care is reimbursed through so-called add-ons.
Add-ons are separate payments that have been devel-
oped for the reimbursement of expensive drugs and
intensive care unit admissions.
From 2012 onwards, the Minister of Health has made
sector agreements with providers and insurers that have
effectively limited spending growth to 2.5% during 2012
and 2013, 1.5% in 2014 and 1% in 20152017. The
agreement included an extra 1% spending growth allow-
ance for primary care practices in 2014 and 1.5% in
20152017, provided they demonstrate that their ser-
vices are a substitute for hospital care.
Insurers and hospitals negotiate prices and volumes on
a yearly basis, guided by the terms of the sector agree-
ments. Because of the sector agreements, hospitals and
insurers de facto negotiate lump sum contracts with rev-
enue ceilings as the most important provision. In
addition to the ex-ante contracts with stipulated prices
and volumes, a small part of hospital spending - for
non-steerableand very expensive services, including
transplant care and expensive drugs - is carved out from
the revenue ceiling and funded on a fee for service basis.
Hospitals and insurers negotiate 1) carved out con-
tracts for expensive services, using add-on payments
based on fee for service and without cap (in Dutch
nacalculatie) and 2) ex ante a revenue ceiling contract
based on prices and volumes (in Dutch plafondafspra-
ken). Although the agreements allow for differentiation
in percentages growth per hospital, the growth norm is
used as a guiding principle for the negotiations. During
the year, hospitals and insurers discuss new interven-
tions and policy on a continuous basis. In autumn, new
contracts for the upcoming year(s) are negotiated.
The carved-out contracts primarily include expensive
drugs and expensive procedures. The budget for expen-
sive drugs is not part of department budgets, but is a
separate budget. Hospitals and insurers negotiate the
volume and price of expensive cancer drugs, and some-
times also an ex ante determined capped budget. There
are several requirements for carved out contracts, in-
cluding guideline adherence, transparency, and no mar-
gins on the drugs.
Methods
Study design
We chose a multiple qualitative case study design to
study displacement in the hospital sector of the
Netherlands. Case studies are well suited to explore, de-
construct and reconstruct social phenomena, which we
expected the displacement process to be. Our aim was
to obtain the experiences and perspectives of a diverse
range of stakeholders that have been involved in dis-
placement decision making processes. We conducted six
case studies to be able to understand similarities and dif-
ferences between cases. Halfway through the project we
organized an expert meeting with national experts (N=
9) in health economics and policy to discuss preliminary
findings.
We purposefully chose six cost-increasing health
technologies. First, a stakeholder meeting with our fi-
nancial funder (ZINL) was held to identify case stud-
ies meeting a pre-specified set of criteria. In addition,
we searched several (government) websites and ex-
plored cases through our personal networks. Apart
from maximizing heterogeneity, interventions were re-
quired to meet the following criteria: 1) interventions
should be generally considered cost-ineffective based
on current Dutch standards as we were especially in-
terested in decision making concerning new health
technologies with disputable value to inform future
decision making 2) interventions should be provided
in hospitals 3) the reimbursement decisions should
have been made at least 1 year ago, in order to be
able to identify possible displacement effects 4) the
intervention should have a relatively high budget im-
pact. Based on these criteria, we chose intramural
cancer drugs, robotic (Da Vinci) surgery, Left Ven-
tricular Assist Device, endovascular aneurysm repair,
population screening for colon cancer (which itself is
strictly speaking not part of the hospital care, but the
follow-up is), and expensive eye injections (Eylea and
Lucentis). A short description of the interventions is
given in Table 1.
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Participant selection and recruitment
We purposefully selected key stakeholders to be inter-
viewed for the case studies. Key stakeholders were initially
identified from policy documents, websites, the media or
from our network. These key informants all held senior
positions in their hospital (department heads, professors,
senior medical staff, department/division managers) and
occupied key positions within their professional/scientific
field (chairs of committees covering the case-study in the
national scientific association). We then asked the initial
key informants to suggest other participants (snowball
sampling) with understanding of the (displacement) deci-
sion making surrounding the particular technology. We
aimed to take into account geographic spread, to recruit a
diverse set of relevant stakeholders, with different posi-
tions and responsibilities, per case study as well as per
hospital within a case study. For example, we aimed to re-
cruit informants from general, specialized as well as aca-
demic hospitals, and we recruited medical doctors,
financial managers, sales managers, board members, and
health care purchasers (insurers). In addition, we selected
hospitals based on their level of scale up activity in a case-
study; in other words, we recruited hospitals that were af-
fected heavily financially by the entry of the case-study.
All respondents held senior positions within their organ-
isation. Participants were invited to participate in the
study by e-mail. The invitation letter provided a summary
of the aim and methodology of the study, as well as the
time needed for the interview. We sent reminders when
we did not receive a response within 2 weeks.
In total 84 interviews were conducted. Table 2pre-
sents the characteristics of the respondents for each of
the case studies. A minimum of nine interviews were
held per case-study. Medical doctors were generally
overrepresented among our respondents. However, in
each of our case studies we interviewed a diverse range
of stakeholders, with at least four distinct roles and re-
sponsibilities in the Dutch health system.
Data collection
The interviews took place between September 2016 and
May 2017. All interviews per case study were conducted
by one single interviewer. The interviews and analysis
were undertaken concurrently and iteratively, in order to
inform subsequent interviews. For example, we used
subsequent interviews to verify and deepen statements
in the former interview in order to better interpret state-
ments, or to discuss aspects that the former respondents
was not familiar with. The interview team met at least
monthly during the duration of the study to discuss the
findings and to coordinate ongoing work.
The primary aims of the interviews were to identify
the main (financial) consequences of the introduction of
the particular health technology for the department, hos-
pital or insurer; and to discuss the choices and decisions
that were made, as well as the reasons for making the
decisions.
A semi-structured topic guide was used for the inter-
views, including the introduction process of the health
technology; agreements and negotiation processes with
third party payers; problems encountered (costs, time,
facilities, etc.) due to the introduction of the health tech-
nology; what action was taken in response to the prob-
lems; the consequences for care provision and rationing;
and views concerning displacement (the interview guide
is presented in Additional file 1). Rationing was opera-
tionalized according to Kleins rationing strategies, in-
cluding rationing by denial, selection, delay, deterrence,
deflection and dilution [7].
The topic guide was based on relevant literature and a
pilot study and adapted based on the first five interviews.
We made minor amendments to the topic guide for our
Table 1 Description of the case studies
Health technology Description
Left ventricular assist
device (LVAD)
LVADs are devices for assisting cardiac circulation. They have been used from 1992 onwards as a bridge to transplantfor
patients with advanced heart failure. During the years, the outcomes of the therapy have steadily improved, such that
LVAD can be used as long-term therapy (destination, LVAD is not followed up by a heart transplant).
Fenestrated endovascular
aneurysm repair
In this procedure an expandable stent graft is placed within the aorta to treat aortic disease. This minimally-invasive
technique is indicated for high-risk patients unfit for open surgery. Fenestrated and branched EVAR (FEVAR) are expensive
due to its custom-made graft device.
Expensive oncolytics In recent years, several relatively expensive oncolytics have been approved for inclusion in the basic benefit package,
including pertuzumab, palbociclib, nivolumab, pembrolizumab, atezolizumab, and ibrutinib.
Eylea and Lucentis Avastin, Eylea and Lucentis are all used for the treatment of various eye diseases. Eylea and Lucentis are both much more
expensive than Avastin, but are equally effective for most indications. Eylea and Lucentis are indicated for patients for
whom Avastin is not effective, and for patients with diabetic macula edema and vascular occlusion.
Population screening
for colon cancer
In 2014, the Netherlands started population screening for colon cancer. People with positive test results are advised to get
a colonoscopy in the hospital. Studies have shown that this surveillance is not cost-effective [13].
Robotic surgery Robotic assisted minimally invasive surgery has been performed in the Netherlands since 2000, as an alternative to pure
laparoscopy or open procedures for various indications. Despite many studies, there is still no clear-cut evidence regarding
the cost-effectiveness.
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Table 2 Interview informants and roles per case study
a
Left ventricular assist
device
b
Fenestrated endovascular
aneurysm repair
b
Expensive cancer drugs Eylea and Lucentis Population screening
for colon cancer
Robotic surgery
Medical doctors 5 8 12 8 8 6
Managers/directors 2 3 1 1 2 2
Professional scientific
associations
11 11
Patient associations 1 1 1 1
Manager sales 1 3 1 1
Board of directors 1 1 5 4 4 2
Insurer 1 1 1 1 2
Hospital pharmacists 3
Other 11
Hospital respondents
recruited from:
Recruited from three
university medical
centres
Recruited from two
general hospitals, four
university medical centres
Recruited from four
general hospitals, five
university medical
centers
Recruited from two general
hospitals, two specialized
clinics, four university
medical centers
Recruited from six
general hospitals,
four university
medical centers
Recruited from six
general hospitals,
three university
medical centers
a
Informants may be listed on several roles or columns. For example, a medical doctor may be a part-time member of the sales team of the hospital, or a member of the board of directors may have spoken about two
or more case studies
b
We interviewed active members of the professional scientific associations (f.e. members of guideline committees), but not formally as representatives of the professional scientific association
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interviews with hospital boards members and health in-
surers. During these interviews we discussed multiple
case studies, and more time was devoted to displacement
processes and priority setting in general.
The interviews were predominantly conducted face to
face, at the respondents office, but twenty interviews were
conducted by telephone. Interviews ranged 2060 min
and were audio-recorded and transcribed verbatim. Per-
mission for audio recording was sought for and given in
every case. The purpose of the interview and the general
aim of the study were summarized at the start of each
interview. We explained that neither findings nor quotes
would be attributed to individuals or organizations.
Data analysis and presentation
Transcripts were transcribed verbatim and analyzed
thematically in Atlas.ti on the basis of an item list.
This item list was derived from the semi-structured
topic guide and literature. We made minor modifica-
tions to the topic list based on discussions within the
broader study team. All analyses were performed by
the interviewer who held the interview. In case of
data ambiguity, we contacted the respondents to re-
trieve the meaning of a quote. For the purpose of
inter-researcher reliability, the interviewers met regu-
larly to discuss themes and data categories. In
addition, at the start of the analysis, at least one tran-
script per case study was independently coded by two
or more researchers and the results were compared.
Any differences in data interpretation were discussed
and resolved, and the approach was repeated until the
researchers met satisfactorily levels of agreement.
We developed summary tables of the case studies ac-
cording to the categories of the item list and compared
the results across the case studies to identify systematic
patterns of displacement. Based on this information, a
narrative summary of the results was made. The results
are presented according to the flow chart below (Fig. 1)
which follows the budgetary flow in the health system
and our interview guide. The arrows of the flowchart in-
dicate how stakeholders can (re-)allocate the budget
pressure, either upwards (left side), or downwards (right
side). The green circles correspond with the paragraphs
in the results section.
Fig. 1 Macro model budget pressure, stakeholder model
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We first present respondent characteristics, and then
discuss the introduction process of the health technology
and actors involved; agreements and negotiations with
insurers; problems encountered (costs, time, facilities,
etc.) due to the health technology; decision making
process in response to the problems; the consequences
for care provision and rationing; and views concerning
displacement.
Results
Below the main findings of the interviews are presented.
Paragraph 3.1 and 3.2 provide main contextual findings
concerning the health technologies; which are essential
for understanding the displacement mechanisms that
will be outlined in paragraph 3.3 until 3.5.
Entry into hospitals
An elaborate description of our research findings per
case study is presented in Additional file 2. Entry into
hospitals differed between cases. In most of the case
studies, a wide range of stakeholders were involved in
decision making processes, including health profes-
sionals, managers of hospital departments, board of di-
rectors, investment or drug committees, and in some
cases also stakeholders from outside the hospital (med-
ical societies, healthcare inspectorate, ZINL, other gov-
ernmental agencies). However, in case of FEVAR,
specialists and departments started experimenting with
one or a few test procedures, before activities were
scaled up after which stakeholders at a higher hierarchy
level of the hospital were involved. LVAD, FEVAR,
Lucentis and Eylea were all already used at considerable
scale before they were formally included in the basic
benefit package.
Reimbursement, contracts and negotiation with insurers
According to the respondents, the reimbursement of
cancer drugs is generally undisputed, and insurers will
reimburse on basis of fee for service, as they fear for loss
of reputation. However, indication extension during the
year has led to budget overruns in some hospitals that
were unable to negotiate extra money.
For remaining medical care, we found that negotia-
tions about the capped revenue are parallel to, or subse-
quent to negotiations of the carved-out contracts.
Hospitals generally prepare long lists of services they re-
quest additional funding for, and similarly insurers pre-
pare lists of services they are willing to withdraw
funding for. Based on the experience of our respondents,
occasionally individual items on such lists are discussed
and accepted or rejected. Hospital and insurer primarily
negotiate a revenue cap, which is secondarily based on
prices and volumes. Terms about specific services are
not binding and may be exchanged for any other
services. In addition, cross-subsidization (services are
paid from the margins of other services) was widely
reported.
Problems encountered
The interviewees reported a wide range of problems they
were faced with when the intervention was introduced.
In case of LVAD and population screening for colon
cancer, participants reported predominantly capacity
problems (increased need for specialized personnel, op-
erating room capacity, intensive care beds, colonoscopy
capacity) and only limited financial problems. For the
remaining four technologies, both capacity problems as
well as financial problems were reported. Below the fi-
nancial problems, and problems intrinsically related to
displacement, are outlined.
Investment opportunities exceed the permitted growth
Both insurers and hospital management generally did
not doubt the added value of most investment oppor-
tunities. However, it was clear that the associated total
costs could not be accommodated in the current growth
path. Many respondents argued that the increase in ex-
pensive drugs was at the expense of other services. It
was hard to say however, at what expense exactly.
If that were not the case, then the rest of the negoti-
ations might have been a lot easier. The expensive
drugs are the elephant in the roomBoard of
directors.
Respondents generally pointed to the totality of budget
increases, rather than to the growth of individual drugs
or services. For example, FEVAR was one of a range of
services contributing to the cumulative budget overrun.
As a result, what could be observed is a competition be-
tween technologies and services for spending growth.
Instead, we do complicated things, like FEVAR-
prostheses, complicated laparoscopic operations and
so on. That costs twice as much, but our budget does
not grow. So at the meso level of the department,
there is a continuous fight with the Board of Direc-
tors.Vascular surgeon.
From the interviews it appeared that the degree of ex-
perienced cost pressure differed between settings, de-
pending on the financial organisation of the hospital and
negotiating power. Three respondents reported that the
cost pressure in surgical departments/divisions was more
severe than in cardiology/cardiothoracic divisions.
In addition, respondents argued that smaller hospitals
face higher risks for cost pressure due to expensive
drugs, as they were less likely to negotiate generous
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contracts with insurance companies. In the eye drugs
case, specialized eye centres experienced heavier cost
pressure, as they had less abilities for cross-subsidization
or abilities to exchange services.
The distribution of flow of funds within a hospital is not
transparent
Especially in larger and academic hospitals, many rev-
enue sources exist, including innovations funds, educa-
tion fees, research funds and others. According to our
respondents, hospitals use internal funds through which
the various revenue sources are reallocated (services
were exchanged, or through cross-subsidization).
We work with a budget system. We negotiate on
how that budget is built up, but it is up to the
healthcare provider how to fill in that budget. A
healthcare provider always has the possibility to re-
allocate the money somewhere else instead of to that
DRG.Insurer.
Respondents reported a lack of transparency in the
hospitals internal financing. In the current system, ne-
gotiated DRG-prices may not represent real prices, and
hospitals may lack insight in the costs of their DRGs.
According to the respondents, negotiations rarely take
place on intervention or technology level and are mostly
based on hospital revenue deals. Consequently, the add-
itional costs of an intervention or displacement effects
are hardly visible.
The system is not so one-dimensional that such ef-
fects are immediately visible and you get a difficult
conversation about the disposables [surgical instru-
ments]. There are many possibilities and sources for
substitution.-Surgeon.
Each hospital employed a sales team to negotiate con-
tracts with insurers on behalf of the board of directors.
Most of the managers and specialists we interviewed
were not, or rarely/hardly involved in negotiations with
insurers. In addition, managers and specialists noted that
they were unaware of the specific provisions of the nego-
tiated contracts. For example, three managers noted that
they were unaware of negotiated prices for specific ser-
vices. In contrast with that, most respondents noted that
their department/hospital budget allowed certain max-
imum volumes for services. However, this maximum
number of services was not necessarily a provision in
contracts with insurers (external budget). Rather, this
volume was used for internal planning in a decentralized
internal budget, which was derived from the external
budget. However, internal budgets may differ signifi-
cantly from external budgets, as long as the revenue cap
is not passed. In other words, provisions of the contract
about specific services are not necessarily binding, and
may be exchanged for other services, or allow cross-
subsidization.
Decision making processes, underlying reasons and
contra-mechanisms to budgetary pressure
Decision making differs across types of financing, board of
directors are central to decision making
According to our respondents, priority setting and ra-
tioning within hospitals differs depending on the type of
service and type of budget. Expensive drugs requests are
assessed by drug committees, before the Board of Direc-
tors are involved, who may negotiate additional budget
from insurers. Because there is a separate budget for ex-
pensive drugs, the budget pressure was experienced at
the higher managerial levels, not only by the department
that uses the drugs. This budget pressure is (partly) ac-
commodated by insurers and may be indirectly accom-
modated by departments in the hospital through lower
department budgets.
In addition to the budget for expensive drugs, the
hospital budget is cut into budgets for divisions and
(sub-)departments. According to our respondents, de-
partments and divisions are relatively free in how to
spend this budget, but they are kept relatively strictly to
this budget. They discuss their policy, budgets and activ-
ities with the board of directors on a regular basis.
If the cardiologists want to grow in the field of inter-
ventions, then maybe they should not grow in the
area of the fast-track outpatient clinics. -Board of
directors.
Departments and divisions may submit business-cases
to request additional funding. The board of directors
(and sales team) are central to this decision making.
They may decide to include the business-case in negotia-
tions with insurers (external business-cases). Respon-
dents noted that in exceptional cases (long waiting lists)
hospitals have successfully negotiated extra funding. In-
ternal business-cases are not discussed with insurers and
may be rejected or funded from other sources. Most of
the times, the board will request the departments to take
austerity measures (see Contra-mechanisms). In each of
the cases, the board of directors was involved in intro-
ductory decision making or growth.
Strategic considerations and key topics
A range of arguments were mentioned for introducing a
technology, or to further invest in the growth of a par-
ticular service. In all case studies, patients were expected
to benefit from the treatment. In addition, respondents
argued that the technology was considered a key topic of
Wammes et al. BMC Health Services Research (2020) 20:263 Page 8 of 12
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the department and the hospital. Such emphasis on key
topics can take many forms, and key topics were chosen
at every managerial level (e.g. from high to low: cardio-
vascular centres, vascular surgery, aorta pathology). Gen-
erally speaking, such key topics receive more funding, at
the expense of others.
In the coming years in particular the cardiothoracic
and vascular domain will grow, maybe at the ex-
pense of others. That we say in other respects, that is
no longer for us.-Board of directors.
Besides, several respondents pointed to competition
between providers: providers were afraid to lose patients,
or were afraid to stay behind technologically.
If we limit that flow of patients, then we will lose it,
then theyll look for someone else. Until today, that
was one of the reasons why we accept the budget
overrun.-Surgeon.
Some respondents doubted the benefits of the treat-
ment and noted that a clear evidence base was lacking.
Cost-effectiveness was rarely considered in introductory
decision making. Besides, respondents argued the indus-
try had pushedthe technology too much.
Contra-mechanisms
We asked the respondents how they dealt with the
budget pressure of the new technologies. Respondents
primarily pointed to their choices in the portfolio of
their services. Insurers and the board of directors may
request departments to stop providing services that can
be provided elsewhere at lower costs.
Someone with a minor heart attack, and when
treatment has gone straightforward, should simply
be followed-up elsewhere.Cardiologist.
Some respondents doubted the budget impact of such
measures, although it effectively reduced work load.
Hospitals increasingly collaborate in this re-arrangement
of service delivery, but the degree of collaboration differs
considerably across hospitals.
A variety of other measures were mentioned to re-
lieve budget pressure or capacity problems. This in-
cluded efforts to reduce the price of LVADs, FEVAR-
stents, and expensive drugs. Many doctors stated that
they adhered to guideline recommendations more
strictly than before, or that eligibility criteria for pro-
cedures or drugs were redefined. Besides, efforts were
taken to reduce the length of stay or to technically
improve services. Task rearrangements, substitution,
e-health, and cuts in staff and beds were also
mentioned.
Displacement, and impact on regular care
We asked interviewees directly what measures were
taken to accommodate the introduction of the tech-
nology, and which effects this had for regular care
and for individual patients. In case of LVAD, respon-
dents pointed to generous financing, and that prob-
lems primarily occurred due to capacity constraints.
FEVAR was one of the services contributing to cumu-
lative cost pressures, and in some hospitals FEVAR
was rationed due to cost pressures from other ser-
vices. Population screening for colon cancer was also
rationed, but this was primarily due to shortages in
GE-specialists. The additional costs for Da Vinci sur-
gery were largely unknown, and cross-subsidized from
other services.
The budget pressure of expensive drugs was accom-
modated by insurers and the board of directors, who
redistributed this to the rest of the departments (hori-
zontal reallocation). In the eye drugs case, rationing
was widely reported, but cost pressure was only one
of the several factors that necessitated rationing.
With few exceptions, there was consensus in our re-
spondents that displacement, and efficiency/austerity
measures were not causally linked to investments in
technologies.
I cannot but remember that we had to cut costs
and look for efficiency gains. But I cannot say
that this really is at the expense or coincides with
that Da Vinci. That is a permanent system to
level the costs and the revenues.-Manager
urology.
Although not necessarily related to the technologies,
many respondents pointed to current pressures in
Dutch hospitals, and the necessity to ration care.
Below the most important mechanisms are outlined.
Rationing is usually the result of production caps and
capacity problems
Many respondents noted that rationing was the result
of cumulative pressure from several sources, including
aging, reform in long term care, and technological
innovation. Shortages in personnel and beds further
complicated the situation. Occasionally, but not struc-
turally, such capacity problems were related to auster-
ity measures. Furthermore, respondents noted that
individual services were rarely rationed, but that ra-
tioning occurred rather in larger organizational units,
such as surgical divisions, or cardiovascular centres.
Wammes et al. BMC Health Services Research (2020) 20:263 Page 9 of 12
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Several respondents blamed the sector agreements
and argued that insurers do not purchase enough
care.
Hospitals primarily reduce accessibility in response to cost
pressure
Respondents listed all rationing strategies; and rationing
by delay was mentioned most frequently and was
regarded the primary rationing strategy. In case of a
budget overrun or capacity problems, the board of direc-
tors may request departments to reduce accessibility.
Yes, then we consult with the manager and the
head of the department, and tell them to increase
the waiting lists.-Board of directors.
Based on the experience of our respondent, rationing
strategies were usually combined, especially rationing by
delay and selection were often used in tandem. Further-
more, patients were prioritized on the basis of medical
need: patients with cancer and acute patients got direct
access, while non-acute patients were queued.
If your operation room time is limited and you
have to choose, the oncology patient is prioritized,
and you are actually displacing the benign [non-can-
cer] patient.- Director surgical division.
Respondents noted that rationing strategies were used
strategically to redirect patient flow. Hospitals focus
their activities to more narrowly defined subpopulations
or services. Consequently, patients with low complexity
needs (selection) were denied access, or hospitals used
long waiting lists (delay) for low complexity services.
Rationing by selection was often interpreted as a strat-
egy to improve patient care, rather than a method to cut
costs. For most respondents it was difficult to discern ef-
ficiency measures from rationing. Besides, respondents
found it hard to identify the direct consequences for
their patients health. Most respondents mentioned that
competing hospitals had enough capacity to take over
the patient flow. One potentially negative consequence
for patients was increased travel time, and dissatisfaction
due to their inability to go to the hospital of their first
choice.
Discussion
This paper presents how Dutch hospitals have dealt with
the introduction of six cost-increasing health technolo-
gies. According to the experience of our respondents,
the opportunity costs of cost-increasing health technolo-
gies could not unambiguously be identified; limited
transparency in the allocation of funds downstream
within a hospital contributed to this. Furthermore,
respondents noted that the entry of new health tech-
nologies and cost-containment are two parallel processes
that are generally not causally linked. In addition, the
way of financing with a separate budget for expensive
drugs may be pivotal in the Netherlands. According to
the respondents, the budget pressure of expensive drugs
is reallocated horizontally across departments, whereas
the budget pressure of remaining services is primarily
reallocated vertically within departments or divisions.
Respondentshospitals have reacted to budget pressures
primarily through a narrowing in the portfolio of their
services, and a range of efficiency measures. The board
of directors was found central in these processes, while
insurers were involved only to a limited extent. Direct
displacement of high-value care due to the introduction
of new health technologies was not observed; respon-
dents primarily pointed to increased spending and effi-
ciency measures to accommodate the introduction of
the technology. Rationing (primarily reducing accessibil-
ity) was observed mainly in response to cumulative cost
pressures, production caps and capacity problems. In
addition, respondents noted that patients were priori-
tized on the basis of medical need, cancer and acute pa-
tients were prioritized for non-acute patients, and that it
was hard to identify the direct consequences for patients
health.
Our analysis supports and builds on a relatively new
field within health services research, a field that concerns
identifying displacement effects as a response to the
introduction of cost-increasing services, and estimating
implicit threshold values to inform decision making con-
cerning the basic benefit package. In line with Karlsberg
Schaffer et al., our respondents noted that new technolo-
gies were generally accommodated by greater efficiency
and increased spending, and that hospitals sought sav-
ings or efficiency measures in response to cumulative
cost pressures rather than in response to single cost-
increasing technologies [6].
One notable contribution of our research is that we,
based on comparative analysis, identified two distinct
pathways in which new technologies contribute to
budget pressure. The first pathway includes funding for
expensive drugs, which are explicitly appraised for inclu-
sion in the basic benefit package. This budget pressure
was said to be partly accommodated by insurers, and
partly spread horizontally across several departments, al-
beit respondents found it hard to say to what extent de-
partments accommodated the costs of (other
departments) expensive drugs. The second pathway con-
cerns funding for all other (non-pharmaceutical) tech-
nologies, which are rarely assessed by ZINL before entry,
and the costs of which relate to the revenue cap. Our
findings point out that the budget pressure of such tech-
nologies is generally reallocated vertically within the
Wammes et al. BMC Health Services Research (2020) 20:263 Page 10 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
department or division. In addition, cross-subsidization
and abilities to exchange funds were widely reported,
and therefore insurers have limited abilities to control
such spending. There is, however, generally a lack of
clear-cut evidence about the value of the services. One
risk in such implicit decision-making processes is that
policy be based on arguments that may not be in line
with maximizing population health. Indeed, personal fac-
tors (e.g. the powerfulmedical doctor) and competi-
tion between providers were named as arguments for
approving a business-case.
Implications for policy
Our findings indicate that new technologies were gener-
ally accommodated by greater efficiency and increased
spending, and that hospitals sought savings or efficiency
measures in response to cumulative cost pressures rather
than in response to single cost-increasing technologies. In
addition, rationing (primarily reducing accessibility) was
observed mainly in response to cumulative cost pressures,
production ceilings and capacity problems. Such problems
are likely to worsen, given the newly established sector
agreement with decreasing permitted budgetary growth
(1.3% in 2019 to 0% in 2022, excluding wage and price ad-
justment). Possibly, as budgetary pressure increases, more
drastic approaches may be applied to accommodate new
technologies, which may well increase the opportunity
costs of implementation, i.e., making health care as a
whole less efficient. Furthermore, we showed that - albeit
many stakeholders are involved - the introduction of non-
pharmaceuticals is relatively uncontrolled, and that this
may have undesirable effects. It is at this local level for
non-pharmaceuticals where ad hoc decision making is
ubiquitous, and sub-optimal use of scarce resources is very
likely to occur.
Further policy may be aimed at strengthening or im-
provement of this local decision making, to carefully weigh
benefits and costs of risky innovations with necessary stake-
holders before scaling up of implementation. In the Dutch
decentralized system, this may be most feasible, effective
and is in line with the current sector agreements. Such pol-
icies will need all stakeholders to be involved, but especially
board of directors of hospitals. In addition, some decisions
may need to become more centralized. For example, legisla-
tors might consider whether the opendescription of the
benefit package for non-pharmaceuticals could become
more closed, through adoption of cost-effectiveness as an
additional reimbursement requirement in the open system.
One option might also be to extend managed entry agree-
ments to non-pharmaceuticals. Relevant stakeholders might
join efforts to guidethe introduction of new technologies
more prudently, for example through establishing mini-
mum quality requirements, or to facilitate horizon scanning
of new innovations. In addition, insurers might further
develop their procurement policies to more effectively limit
the entry of technologies with uncertain value, for example
through concentrating the entry of innovations in selected
hospitals via earmarked innovations funds for expensive or
high risk innovations. Insurers could more strictly reim-
burse based on negotiated volumes for services, and limit
possibilities for hospitals to exchange funds. In addition,
hospitals could better align their internal budgets with their
external budgets, and limit possibilities for cross-
subsidization and abilities to exchange funds within their
hospital. Finally worth mentioning is a look at other pay-
ment systems, like for example pay for performance.
Strength and limitations
One major strength of our study is that we interviewed a
wide range of stakeholders with diverse positions and re-
sponsibilities in the Dutch hospital sector, including
macro, meso and micro perspectives on cost-increasing
technologies. Especially this comprehensive approach
adds to the present literature on this subject, that was
mainly restricted to the macro or meso level. Although
we claim a comprehensive approach it was not well bal-
anced between stakeholders. For example, insurers were
relatively underrepresented and we did not interview
representatives from the (pharmaceutical) industry.
For most respondents it was difficult to discern effi-
ciency measures from rationing by dilution, and it proved
hard to identify the direct consequences of rationing strat-
egies. As with all qualitative research, our findings may
not necessarily extend to other settings. We purposefully
identified six contrasting case studies, other case studies
might have led to other results. Our analyses primarily
concerned academic or relatively large hospitals, as most
technologies enter the sector in these hospitals. Besides,
our findings are dependent on the Dutch local context,
most notably the way Dutch hospitals are financed and
performances reimbursed. Social desirability or selective
recall bias may have also influenced our findings. There
may be no incentives for respondents to reveal displace-
ment in interviews. However, our research methods were
designed to cope with this problem, as we guaranteed that
neither findings nor quotes would be attributed to individ-
uals or organizations. Besides, we recruited a large number
and diverse set of relevant stakeholders also within hos-
pitals - in order to verify and compare statements. How-
ever, we did not systematically identify similarities and
differences between different groups of stakeholders.
More research is needed to identify displacement
mechanisms in healthcare domains other than the hos-
pital sector. Our research identified two distinct path-
ways of displacement effects, which are intrinsically
linked to financing, and our approach may be fruitful in
other countries as well. Furthermore, our findings once
more point to the plethora of low-value service provision
Wammes et al. BMC Health Services Research (2020) 20:263 Page 11 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
and lack of knowledge of the value of many services.
More research is warranted in disinvestment of low-
value services, and of (early) health technology assess-
ment to prevent the introduction of promising, but
nevertheless low-value services.
Conclusions
Our findings indicate that new technologies were generally
accommodated by greater efficiency and increased spend-
ing, and that hospitals sought savings or efficiency measures
in response to cumulative cost pressures rather than in re-
sponse to single cost-increasing technologies. We found
thattheopportunitycostsofcost-increasing health tech-
nologies are not easily identifiable. Hospitals typically in-
crease efficiency and disinvest in a range of low-value
services, or services that may be provided elsewhere at
lower costs, and decrease the volumes across the totality of
their services. We found that the budget pressure of expen-
sivedrugsisreallocatedhorizontally across departments,
whereas the budget pressure of remaining services is pri-
marily reallocated vertically within departments or divi-
sions. Decision making for entry of non-pharmaceuticals is
often ad hoc and poorly informed by scientific evidence,
which very likely results in sub-optimal use of resources.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12913-020-05086-9.
Additional file 1. Interview scheme
Additional file 2. Results of the case-studies
Abbreviations
ZINL: Health Care Institute; MOH: Minister of Health; NHS: National Health
Service; NICE: National Institute Clinical Excellence; RVZ: Raad voor
Volksgezondheid en Samenleving; QALY: Quality-Adjusted Life Year;
DRG: Diagnosis Related Group; LVAD: Left Ventricular Assist Device;
EVAR: Endovascular Aneurysm Repair; FEVAR: Fenestrated Endovascular
Aneurysm Repair
Acknowledgements
None.
Authorscontributions
JW drafted the first manuscript. JW, GF, PG, DD were responsible for the
case-studies, conducted the interviews and analyzed the data. SE, AP, NS, PJ,
WO and EA made a substantial contribution to the development of the re-
search question and interpretation and presentation of the findings. All au-
thors provided feedback to and approved the final manuscript.
Funding
Zorginstituut Nederland. The funding source had no role in study design; in
the collection, analysis and interpretation of data; in the writing of the
report; or in the decision to submit the manuscript for publication.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
Not applicable. In the Netherlands, only studies which fall under the scope
of the Medical Research Involving Human Subjects Act (WMO) must
undergo a prior review. This applies to all research that meets the following
criteria: (1) it concerns medical scientific research, and (2) participants are
subject to procedures or are required to follow rules of behavior. We did not
submit our study to a medical ethics committee because clearly our
participants were not subject to procedures or required to follow rules of
behavior. Please visit the following website for an elaborate explanation of
the law and criteria: https://english.ccmo.nl/investigators/legal-framework-for-
medical-scientific-research/your-research-is-it-subject-to-the-wmo-or-not
Furthermore, in the Netherlands, it is not obliged by law to seek informed
consent before interviewing health care professionals. However, we did
inform the informants thoroughly (what to expect, their rights and
obligations). No identifiable information has been included in the
manuscript.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Radboud university medical center, Scientific Center for Quality of
Healthcare, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
2
Julius
Center for Health Sciences and Primary Care, University Medical Center
Utrecht, Utrecht, Netherlands.
3
Ecorys, Rotterdam, Netherlands.
4
Department
of Health Services Research, Care and Public Health Research Institute
(CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University,
Maastricht, Netherlands.
5
Radboud university medical center, Health
Evidence, Nijmegen, Netherlands.
Received: 23 August 2019 Accepted: 9 March 2020
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Article
Full-text available
Background: Population-based screening to prevent colorectal cancer (CRC) death is effective, but the effectiveness of postpolypectomy surveillance is unclear. Objective: To evaluate the additional benefit in terms of cost-effectiveness of colonoscopy surveillance in a screening setting. Design: Microsimulation using the ASCCA (Adenoma and Serrated pathway to Colorectal CAncer) model. Data sources: Dutch CRC screening program and published literature. Target population: Asymptomatic persons aged 55 to 75 years without a prior CRC diagnosis. Time horizon: Lifetime. Perspective: Health care payer. Intervention: Fecal immunochemical test (FIT) screening with colonoscopy surveillance performed according to the Dutch guideline was simulated. The comparator was no screening or surveillance. FIT screening without colonoscopy surveillance and the effect of extending surveillance intervals were also evaluated. Outcome measures: CRC burden, colonoscopy demand, life-years, and costs. Results of base-case analysis: FIT screening without surveillance reduced CRC mortality by 50.4% compared with no screening or surveillance. Adding surveillance to FIT screening reduced mortality by an additional 1.7% to 52.1% but increased lifetime colonoscopy demand by 62% (from 335 to 543 colonoscopies per 1000 persons) at an additional cost of €68 000, for an increase of 0.9 life-year. Extending the surveillance intervals to 5 years reduced CRC mortality by 51.8% and increased colonoscopy demand by 42.7% compared with FIT screening without surveillance. In an incremental analysis, incremental cost-effectiveness ratios (ICERs) for screening plus surveillance exceeded the Dutch willingness-to-pay threshold of €36 602 per life-year gained. Results of sensitivity analysis: When using a parameter set representing low colorectal lesion prevalence or when colonoscopy costs were halved or colorectal lesion incidence was doubled, screening plus surveillance became cost-effective compared with screening without surveillance. Limitation: Limited data on FIT performance and background CRC risk in the surveillance population. Conclusion: Adding surveillance to FIT screening is not cost-effective based on the Dutch ICER threshold and substantially increases colonoscopy demand. Extending surveillance intervals to 5 years would decrease colonoscopy demand without substantial loss of effectiveness. Primary funding source: Alpe d'HuZes, Dutch Cancer Society, and Stand Up To Cancer.
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Background: All health care systems face the need to find the resources to meet new demands such as a new, cost-increasing health technology. In England and Wales, when a health technology is recommended by the National Institute for Health and Care Excellence (NICE), the National Health Service (NHS) is mandated to provide the funding to accommodate it within three months of publication of the recommendation. Identifying what, in practice, is foregone when new cost-increasing technologies are introduced is important for understanding the effects of health technology assessment (HTA) decisions on the NHS or any other health care system. Our objective was to investigate how in practice local NHS commissioners in Wales accommodated financial "shocks" arising from technology appraisals (TAs) issued by NICE and from other cost pressures. Methods: Semi-structured interviews were conducted with Finance Directors and Medical Directors from all seven Local Health Boards (LHBs) in NHS Wales. These interviews covered prioritisation processes, as well as methods of financing NICE TAs and other financial shocks at each LHB. We then undertook a systematic identification of themes and topics from the information recorded. The study relates to the period October 2010 to March 2013. Results: The financial impact of NICE TAs is generally anticipated and planned for in advance and the majority of LHBs have contingency funds available to cope with these and other financial shocks within-period. Efficiency savings (defined as reductions in costs with no assumed reductions in quality) were a source of funds for cost pressures of all kinds. Service displacements were not linkable to particular NICE TAs and there appears to be a general lack of explicit prioritisation activities. The Welsh Government has, on occasion, explicitly or implicitly acted as the funder of last resort. Conclusions: Services may be displaced as part of a response to the cumulative impact of all types of cost pressures, including cost-increasing health technologies recommended by NICE, but such displacements were not direct responses to the publication of individual NICE TAs. The additional cost pressure represented by a new NICE TA is likely to be accommodated at least partly by greater efficiency and increased expenditure rather than displacement of services.
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Background: Both rising healthcare costs and the global financial crisis have fueled a search for policy tools in order to avoid unsustainable future financing of essential health benefits. The scope of essential health benefits (the range of services covered) and depth of coverage (the proportion of costs of the covered benefits that is covered publicly) are corresponding variables in determining the benefits package. We hypothesized that a more comprehensive health benefit package may increase user cost-sharing charges. Methods: We conducted a desktop research study to assess the interrelationship between the scope of covered health benefits and the height of statutory spending in a sample of 8 European countries: Belgium, England, France, Germany, the Netherlands, Scotland, Sweden, and Switzerland. We conducted a targeted literature search to identify characteristics of the healthcare systems in our sample of countries. We analyzed similarities and differences based on the dimensions of publicly financed healthcare as published by the European Observatory on Health Care Systems. Results: We found that the scope of services is comparable and comprehensive across our sample, with only marginal differences. Cost-sharing arrangements show the most variation. In general, we found no direct interrelationship in this sample between the ranges of services covered in the health benefits package and the height of public spending on healthcare. With regard to specific services (dental care, physical therapy), we found indications of an association between coverage of services and cost-sharing arrangements. Strong variations in the volume and price of healthcare services between the 8 countries were found for services with large practice variations. Conclusion: Although reducing the scope of the benefit package as well as increasing user charges may contribute to the financial sustainability of healthcare, variations in the volume and price of care seem to have a much larger impact on financial sustainability. Policy-makers should focus on a variety of measures within an integrated approach. There is no silver bullet for addressing the sustainability of healthcare.
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Cost-effectiveness analysis involves the comparison of the incremental cost-effectiveness ratio of a new technology, which is more costly than existing alternatives, with the cost-effectiveness threshold. This indicates whether or not the health expected to be gained from its use exceeds the health expected to be lost elsewhere as other health-care activities are displaced. The threshold therefore represents the additional cost that has to be imposed on the system to forgo 1 quality-adjusted life-year (QALY) of health through displacement. There are no empirical estimates of the cost-effectiveness threshold used by the National Institute for Health and Care Excellence. Objectives (1) To provide a conceptual framework to define the cost-effectiveness threshold and to provide the basis for its empirical estimation. (2) Using programme budgeting data for the English NHS, to estimate the relationship between changes in overall NHS expenditure and changes in mortality. (3) To extend this mortality measure of the health effects of a change in expenditure to life-years and to QALYs by estimating the quality-of-life (QoL) associated with effects on years of life and the additional direct impact on QoL itself. (4) To present the best estimate of the cost-effectiveness threshold for policy purposes. Methods Earlier econometric analysis estimated the relationship between differences in primary care trust (PCT) spending, across programme budget categories (PBCs), and associated disease-specific mortality. This research is extended in several ways including estimating the impact of marginal increases or decreases in overall NHS expenditure on spending in each of the 23 PBCs. Further stages of work link the econometrics to broader health effects in terms of QALYs. Results The most relevant ‘central’ threshold is estimated to be £12,936 per QALY (2008 expenditure, 2008–10 mortality). Uncertainty analysis indicates that the probability that the threshold is
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With the introduction of the Health Insurance Act in 2006 in the Netherlands, the basic package of the former sickness funds became valid for all citizens. The basic benefit package has been subject to change, responding to increasing health care expenditures, medical innovations and the economic crisis. In this paper we address the decision criteria used to assess the package annually since 2006 and describe some developments that do not follow the criteria, leading to a yo-yo effect. We discuss the formation of the decision for in- or exclusion and why some treatments seem to follow an, at first sight, arbitrary in- and exclusion pathway. We first describe the official way of establishing the basic benefit package and than will describe why some treatments follow a deviated path. We conclude that political pressure and pressure from interest groups may lead to inclusion or postponement of exclusion. Reform of the organization of certain forms of health care (in our example mental care) may lead to seemingly inconsequent changes. The yo-yo effect of some treatments or pharmaceuticals may have negative effects on health care providers, insurers and patients. The seemingly well defined criteria available for defining the basic package appear to be broadly interpretable and other influences may determine the final decision of inclusion or exclusion.
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In the UK, approval decisions by Health Technology Assessment bodies are made using a cost per quality-adjusted life year (QALY) threshold, the value of which is based on little empirical evidence. We test the feasibility of estimating the "true" value of the threshold in NHS Scotland using information on marginal services (those planned to receive significant (dis)investment). We also explore how the NHS makes spending decisions and the role of cost per QALY evidence in this process. We identify marginal services using NHS Board-level responses to the 2012/13 Budget Scrutiny issued by the Scottish Government, supplemented with information on prioritisation processes derived from interviews with Finance Directors. We search the literature for cost-effectiveness evidence relating to marginal services. The cost-effectiveness estimates of marginal services vary hugely and thus it was not possible to obtain a reliable estimate of the threshold. This is unsurprising given the finding that cost-effectiveness evidence is rarely used to justify expenditure plans, which are driven by a range of other factors. Our results highlight the differences in objectives between HTA bodies and local health service decision makers. We also demonstrate that, even if it were desirable, the use of cost-effectiveness evidence at local level would be highly challenging without extensive investment in health economics resources. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
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The UK's National Institute of Health and Clinical Excellence (NICE) has an explicit cost-effectiveness threshold for deciding whether or not services are to be provided in the National Health Service (NHS), but there is currently little evidence to support the level at which it is set. This study examines whether it is possible to obtain such evidence by examining decision making elsewhere in the NHS. Its objectives are to set out a conceptual model linking NICE decision making based on explicit thresholds with the thresholds implicit in local decision making and to gauge the feasibility of (a) identifying those implicit local cost effectiveness thresholds and (b) using these to gauge the appropriateness of NICE's explicit threshold. Structured interviews with senior staff, together with financial and public health information, from six NHS purchasers and 18 providers. A list of health care services introduced or discontinued in 2006/7 was constructed. Those that were in principle amenable to estimation of a cost-effectiveness ratio were examined. It was feasible to identify decisions and to estimate the cost-effectiveness of some. These were not necessarily 'marginal' services. Issues include: services that are dominated (or dominate); decisions about how, rather than what, services should be delivered; the lack of local cost effectiveness evidence; and considerations other than cost-effectiveness. A definitive finding about the consistency or otherwise of NICE and NHS cost effectiveness thresholds would require very many decisions to be observed, combined with a detailed understanding of the local decision making processes.
2015 international profiles of health care systems
  • E Mossialios
  • M Wenzl
  • R Osborn
  • D Sarnak
Mossialios E, Wenzl M, Osborn R, Sarnak D. In: Fund C, editor. 2015 international profiles of health care systems; 2016.
Zoetermeer: Zinnige en duurzame zorg
  • Raad Voor De Volksgezondheid En Zorg
Raad voor de Volksgezondheid en Zorg. Zoetermeer: Zinnige en duurzame zorg; 2006.