Dutch consider excluding costly treatments from health insurance
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7559.113-a (Published 13 July 2006) Cite this as: BMJ 2006;333:113Data supplement
Dutch council proposes excluding costly treatments from health insurance cover
Utrecht
Tony Sheldon
A new report commissioned by the Dutch government says that very expensive treatments should no longer be covered by the country’s health insurance system.
It says that the system should not cover treatment that costs more than €80 000 (£55 000; $105 000) for every extra quality adjusted life year (QALY).
Doctors and patients’ groups are concerned that such proposals could exclude treatments such as liver transplantations for people with liver damage resulting from alcohol misuse and argue that care should not be decided just on financial criteria.
The health minister ordered the report from the Council for Public Health and Care amid fears that health spending is increasing faster than economic growth.
The report argues that decisions on what treatments are covered by health insurance should be based on objective criteria about their effectiveness and cost, as well as the seriousness of the illness.
It says that decisions are currently made in an ad hoc way, under pressure from interest groups and the media and depending on local hospital budgets. For example, a "postcode lottery" exists for women who need trastuzumab (Herceptin). In 2004 in Friesland in the north of the country 6% of women who needed trastuzumab received it, whereas in Zeeland in the south the figure was 86%.
The council argues that its report offers criteria for achieving greater transparency in decision making.
It proposes a system that would first look at whether the cost is justified by the benefit of the treatment. The ceiling for costs would be based on the World Health Organization’s definitions of QALYs. It says this ceiling should be set by politicians, but it believes a realistic figure would be €80 000 per QALY.
At the other end of the scale cheap treatments may also be excluded if the conditions they treat are not serious enough, such as colds or onychomycosis.
The council also proposes a second step in which wider society could say whether such decisions are justified.
Exceptions could be made if, for example, a small number of patients need an expensive treatment. On this basis the rare metabolic condition Gaucher’s disease—the treatment for which, imiglucerase, costs £105 000 a year—might qualify.
The report highlights the current lack of knowledge about the cost effectiveness of treatments, especially for the classes of conditions that are most expensive to treat, mental impairment and dementia, where "scarcely any data exist," it says.
The council member Anton Westerlaken, who chairs the management board of an organisation for mentally impaired people, said: "We need to achieve objective, fair, and verifiable criteria [for health spending]. On the basis of this objectivity we can then test whether the results are socially acceptable."
The Dutch Medical Association has welcomed the debate on cost effectiveness but doubts that the council’s solutions will achieve the desired results. It states that care should be determined in the first instance by the merits of individual cases and not by financial criteria.
Patients’ groups say that putting a cap on the cost of care is "socially irresponsible."
The report, Zinnige en duurzaame zorg (Sensible and Lasting Care), is available in Dutch at www.rvz.net.
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