RHC Week 5 Flashcards
Compulsory health insurance Belgium
- > 99% of the population is covered
- Broad benefits package
- Private, non-profit sickness funds
- Low membership cost (+-8,25 Euro per month) covers insurance services (so insurance/care paid through social security contributions)
Role of NIHDI (National Institute for Health and Disability Insurance)
- Directed by representatives of government, trade unions, providers, sickness funds
- Financed through taxes and social security contributions
- Distributes resources between health insurers (Similar to Germany)
- They enforce and set the “rules of the game”: e.g. reimbursements, track expenditures, “administrative police” for providers and insurers
- The NIHDI decides what is in the benefits package.
Provision Healthcare Belgium
- Providers are mainly paid fee-for-service, partially DRGs Diagnoses Related Costs Groups (57) for some types of hospital care
1. The system is relatively small - Patients are largely free to choose their provider (referrals may shorten waiting list)
1. They do not need a referral. But when you are reffered, the process will be quicker. May shorten waiting lists. What can happen is that your appointment will take longer than when you first go to the GP
Patient Payments Belgium
- Outpatient care: patients pay full price, and get reimbursed (partially) afterwards. Pay full price on the spot. Still pay some of the price but get reimbursed a bit.
- Inpatient care: third-payer arrangements; only pay your share on the spot. Only pay the 6 euros in the spot. Zo willen ze het ook gaan regelen in de outpatient gaan doen.
- There is a maximum expenditure threshold (maximumfactuur) that depends on household income. Above this threshold, households do not longer pay copayments income dependent (verschillende thresholds voor hoog of laag inkomen) 250 ipv 450 geworden sinds dit jaar.
Quality of curative care Belgium
quality of care is average, with signs of improvement
Most aspects of the quality of care are situated within the EU-15 average, with some better points, such as a low mortality from causes avoidable through the health system or colorectal cancer survival, and some weak points, such as indicators in the appropriateness of care (for instance prescription of antibiotics or medical imaging exams) and in safety (i.e. prevalence of hospital-acquired infections). However, a favorable evolution is observed, in the coordination of care for cancer patients, for the proportion of diabetic patients using insulin following a care pathway, in avoidable admissions for diabetic patients, in AMI-case fatality rates and in MRSA infections in hospitals.
High patient satisfaction
From a patient’s perspective, the assessment was quite positive: the Belgian population reported to be satisfied with their contacts with the health system, in ambulatory care as well as in hospital setting. However, some results were not recent and a more balanced image appears when examining the whole set of indicators.
Schokkaert & VdVoorde about belgium
“… Belgians are quite satisfied with their health care system [1]. In these circumstances, one cannot expect politicians to have the desire, the courage and the power to introduce drastic changes. Indeed, such changes have not been introduced: expenditures have kept growing faster than in most other countries.”
When people are satisfaction, there is no need felt for certain reforms or something. But expenditures keep growing. There might be too little rationing
Supply-side rationing Schokkaert
- Setting of a global budget (defined by health insurers, providers and NIHDI); closed end budgets in Belgium. Growth norm takes the limit from last year.
- Growth norm: maximum expenditure increase of 2,5% (before 2020 1,5)
- Possibility for exceptions
- Global budget divided in partial budgets/targets: in case of overrun the fee schedule is adjusted (lower payments for providers) or an increase in co-payments (more payments by patients) is undertaken.
Supply is effectively rationed this way
3 different types of quotas
- numerus fixus
- quota on some hospital/inpatient services
- quota/restriction on number of hospitals that can provide certain type of care
- numerous clausus/fixus
federal advice fixed number of students allowed to enter Medical studies. This numerus clausus is intended to match supply and demand on the market for healthcare services. However, there is a recurring concern on a shortage for GPs (while there are increasing numbers of specialists). This signals a mismatch within the healthcare sector. To reduce this mismatch, quota were suggested to be specialism-specific
- quota on some hospital/inpateint services
E.g., number of hospital beds: not increasing since 1982 – one extra bed comes at the cost of a bed elsewhere. (KCE Report 289As, p. 9)
The number of beds (in relative population terms) is rationed, but the system is currently under reform.
- quota/restriction on number of hospitals that can provide certain types of care
From cancer registry: crucial to have enough expertise to perform highly technical procedures
How des the situation of an insured individual look like? (Belgium)
- Patient pays copayment (possibly after first paying everything upfront)
E.g.: GP visit; 25 euro on the spot, 19 euro reimbursed afterwards - There is a maximum expenditure threshold (maximumfactuur) that depends on household income. Above this threshold (+-450 euro for the lowest income households in 2022 a new bracket which lowers this to 250 euro), households do not longer pay copayments.
- Because of healthcare insurance, there is likely an issue with moral hazard. Since individuals do not bear the full cost of care, they are more likely to 1) use more care (ex-post moral hazard), 2) behave differently (ex-ante moral hazard). The spot-price and copayments try to reduce this.
Structure of Health Care in the UK
Archetypal ‘Beveridge-style’ national health service with universal coverage and few payments at point of use
Operates with a fixed annual budget, determined by the Ministry (Department) of Health and Social care
Financed mainly from general taxation, although there is a small component funded through national insurance
Apart from emergency care, access to the system is through a general practitioner (family physician)
Slightly different arrangements in the 4 constituent countries of the UK (England, Scotland, Wales and Northern Ireland)
Generally regarded as a ‘national treasure’
Copayments
Prescription charges (with exceptions for the poor, children and the elderly)
Dentistry and Optometry (excluding children)
Long-term care for the elderly (shrinking public sector)
Out-of-pocket expenses (eg travel, parking charges)
Note: the biggest cost people bear in the UK NHS is the cost of their own time in seeking and receiving health care
Rationing by Waiting Time
The fixen annual budget for the NHS means that there are several physical limits on the resources available, such as hospital beds, nurses and some categories of physicians
Given the demand for health care, this translates to long waiting lists for some services
(Recent data suggest that more than 7 million people are currently waiting for the care under the NHS)
Measures to shorten waiting times or to manage waiting lists
Waiting list targets, with or without penalties to NHS organisations
Offering patients more choice and increasing competition
Prioritising waiting lists, so that patients with the biggest potential health gain are processed quicker
Rationing by Location
All medicines are completely free in Scotland, Wales and Northern Ireland, but not in England
Scotland also has greater publicly-funded access to social care for the elderly
Groups of local GPs (Clinical Commissioning Groups) may have different policies on access to some services, leading to ‘postcode’ rationing
More wealthy areas may attract more health professionals and have the local tax base to provide some forms of social care
Rationing by Socio-economic status
Having greater knowledge of health care may help patients navigate the system better, although little formal evidence on this
Some people have private health insurance in addition to NHS cover (approx.10%), or are able to pay for some services privately (eg a surgical consultation, or the surgery itself)
Some forms of health care have very limited public provision for adults (eg dentistry, optometry) and most people pay privately
Rationing by science
the motivations behind the establishment of the National Institute of Clinical Excellence (NICE) in 1999 were to:
- tackle postcode rationing
- identify technologies that were both clinically and cost-effective so that they could be given priority for patient access
- use hTA to asses which treatments were good ‘valye for money’, hence leading to better use of NHS budget
Objectives of system like NHS in the UK are
- income protection (e.g. for the poor)
- equality of opportunity (e.g. access to care according to health ‘need’
- maximizing the total health gain from the healthcare budget
What is ment by ‘need’ clinically
= meaning that a person has a health condition which can be treated and that the person desires treatment
‘Need’ defined by Maynard (2013)
= to mean that a person has a health condition for whcih there is a clinically and cost-effective treatment (bearing in mind the importance of opportunity cost in the allocation of health care resources)
Health eco def of ‘need’
= the extent of a person’s absolute or proportional ‘QALY shortfall’
Judging rationing by waiting time
- rarely denies care altogether, but delays could lead to worse outcome for patients (eg detection of cancers)
- discrimintation against individuals who might lose income from time off work, or whom have difficulty making appointments because of inflexibility in their working arangements
- might help perpetuate inefficiencies in HCS
Potential inefficiencies
- repeating tests
- out-dated methods of communication with patients
- involving both the specialist and primary care physician at the same time
- consuming considerable amount of patient time and out-of-pocket costs, although this ensures that NHS resources are not idle
Judging Rationing by location
- Likely to introduce inequalities (unless funding differentials have been introduced to reduce inequalities)
- variation in practice (eg by CLinical Co mminssioning Groups) is often considered to suggest inefficiencies, unless viaraitons can be explained by local differences in need or hc provision
Judging rationing by socio-ec status
- private options clearly introduce inequalities
- In recent years, efforts have been made to ensure a clearer separation of NHS and private care, by:
- reforming clinical specialists’ contracts
- separating public and private facilities
- monitoring of specialists’ waiting lists
Judging rationing by science
Controversial, as it involves explicitly denying access to therapy for some patients
Consistent with the Maynard definition of ‘need’ and with maximizing the overall health of the population, given the resources available
Questions have been raised about the methods used to assess the cost-effectiveness of therapies
A critical issue concerns the level of the ‘cost-effectiveness threshold’ and how this is set
Requires a substantial amount of political will
NICE
Founded in 1999
An Executive Non-Departmental Public Body (ie independent of government, but publicly funded)
Has several programmes of work related to the provision of guidance to the NHS
NICE’s net expenditure for 2020-21 was around £50 million, but NICE also leverages considerable amounts of other resources (eg the time of experts on its committees)
Similar organisations exist in a number of countries (eg ZIN in the Netherlands)
Rationale behind NICE’s approach
HTA needs to be comprehensive, covering all types of health technologies
Methods need to be standardized, but also reflect the particular features of different types of technologies
HTA needs to be applied to both current and emerging technologies
HTA needs to consider both ‘clinical and cost-effectiveness’
NICE’s Technology Assessment Programm
= considers the clinical and cost-effectiveness of new health technologies (covers drugs, medicinal devices and procedures, but last 3-4 years mainly cancer drugs)
–> often leads to restrictions in, or refusal in coverage for, the technologies concerned
(positive recommendations must be implemented by the NHS in England within 3 months)
Methodological shortcoming of QALYs
QALYs are not ‘utilities’ or ‘preferences’, but just a measure of health gain based on individuals’ valuations of health states
QALYs are based on assumptions that probably do not hold
- interval scale (all equivalent changes on the valuation scale are worth the same value)
- constant proportional trade-off (the length of time in a health state does not affect an individual’s valuation of it)
- additive independence (the order in which individuals experience health states does not affect their value of a state)
QALYs do not reflect all the social value gained from health interventions
- convenience of therapy, treatments for serious diseases, scientific spillovers, etc.)
So why do decision makers in the uk use QALYs
The main benefits of health care are the gains in length and quality of life
The QALY is a metric that can be used, in a standardized fashion, for a sequence of decisions about health technologies in a range of disease areas
The inadequacies of QALYs can be compensated for in a ‘deliberative decision-making process’
The alternative approaches, such as estimates of ‘added clinical value’, used in France and Germany, lack transparency and decisions are hard to defend
Other stated preference approaches, such as Discrete Choice Experiments (DCEs) and Multi-Criteria Decision Analysis (MCDA), are not currently sufficiently ‘standardized’ for use in these decisions
Cost-effectiveness threshold
= to assess whether particular interventions are cost-effective, it is necessary to compare them with a pre-determined cost per QALY threshold
–> In the UK, NICE has (historically) used a threshold range of £20,000-30,000 per QALYgained, based on experience from previous decisions
Determining the cost-effectiveness threshold
The threshold can be based on (i) the opportunity cost of services displaced (ii) the societal willingness to pay for health gains, or (iii) aspirations about the level of health care spending (eg the former WHO guidance of 1-3 times GDP per capita)
Most health economists prefer the opportunity cost approach, which treats the health care budget as being exogenously determined by the political process
Under this approach, the threshold cannot be set independently of the health care budget
Thresholds for highly specialized technologies
= In NICE’s HST programme, which includes drugs for rare diseases, a threshold of £100,000 per QALY is allowed if the technology adds 10 or more QALYs for the patient
This rises proportionately up to a threshold of £300,000 per QALY, for technologies adding 30 QALYs
Modifiers used by the scottish medicines consortium
- evidence of a substantial increase in life expectancy (>3 months)
- evidence of a substantial improvement in quality of life
- evidence that a sub-group may derive specific or extra benefit
- absence of other therapeutic options of proven benefit
- possible briding to another proven therapie
- emergence of a licensed medicine as the only therapeutic option for a specific indication
Which kind of rationing do we prefer?
‘We have a choice. Do we use science to help us reach consensus on what we are willing to pay for new therapies and innovation, or do we leave individual patients to wrestle with the skyrocketing costs of cancer care and treatment determined by their ability to pay?’
The Cancer Drugs Fund (CDF)
= Originally established as a ‘safety net’ to fund drugs that were not recommended for NHS use by NICE
Since 2016, it has been used to fund promising new drugs that have some uncertainties about their benefit (aka ‘Coverage with Evidence Development)
Has HTA/Economic evaluation been useful in the uk? Pros
- helpen NHS justify restrictions on technologies of limited value, or poor value for money
- help NHS target expensive therapies to patients that experience greatest benefit
- provided sound basis for price negotiations with technology manufacturers, especially for pharmaceuticals
Academic’s Concerns HTA/Economic evaluation
The explicit or implicit decision-making threshold, of acceptable cost-effectiveness, is higher than the average cost-effectiveness of current health care provision
Manufacturers, since they know NICE’s acceptable limit of cost-effectiveness, just price up to the threshold, whereas otherwise prices would have been lower
The process, of considering the incremental cost-effectiveness of new products, gives attention to technologies of marginal value that would otherwise have been ignored by healthcare decision-makers with limited budgets