RHC Week 5

Question 1

Compulsory health insurance Belgium

Answer 1

• > 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)

Question 2

Role of NIHDI (National Institute for Health and Disability Insurance)

Answer 2

• 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.

Question 3

Provision Healthcare Belgium

Answer 3

• 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

Question 4

Patient Payments Belgium

Answer 4

• 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.

Question 5

Quality of curative care Belgium

Answer 5

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.

Question 6

High patient satisfaction

Answer 6

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.

Question 7

Schokkaert & VdVoorde about belgium

Answer 7

“… 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

Question 8

Supply-side rationing Schokkaert

Answer 8

• 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

Question 9

3 different types of quotas

Answer 9

1. numerus fixus
2. quota on some hospital/inpatient services
3. quota/restriction on number of hospitals that can provide certain type of care

Question 10

1. numerous clausus/fixus

Answer 10

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

Question 11

2. quota on some hospital/inpateint services

Answer 11

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.

Question 12

3. quota/restriction on number of hospitals that can provide certain types of care

Answer 12

From cancer registry: crucial to have enough expertise to perform highly technical procedures

Question 13

How des the situation of an insured individual look like? (Belgium)

Answer 13

• 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.

Question 14

Structure of Health Care in the UK

Answer 14

 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’

Question 15

Copayments

Answer 15

 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

Question 16

Rationing by Waiting Time

Answer 16

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)

Question 17

Measures to shorten waiting times or to manage waiting lists

Answer 17

 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

Question 18

Rationing by Location

Answer 18

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

Question 19

Rationing by Socio-economic status

Answer 19

 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

Question 20

Rationing by science

Answer 20

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

Question 21

Objectives of system like NHS in the UK are

Answer 21

• 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

Question 22

What is ment by ‘need’ clinically

Answer 22

= meaning that a person has a health condition which can be treated and that the person desires treatment

Question 23

‘Need’ defined by Maynard (2013)

Answer 23

= 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)

Question 24

Health eco def of ‘need’

Answer 24

= the extent of a person’s absolute or proportional ‘QALY shortfall’

Question 25

Judging rationing by waiting time

Answer 25

- 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

Question 26

Potential inefficiencies

Answer 26

- 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

Question 27

Judging Rationing by location

Answer 27

- 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

Question 28

Judging rationing by socio-ec status

Answer 28

- 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

Question 29

Judging rationing by science

Answer 29

 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

Question 30

NICE

Answer 30

 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)

Question 31

Rationale behind NICE's approach

Answer 31

 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’

Question 32

NICE's Technology Assessment Programm

Answer 32

= 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)

Question 33

Methodological shortcoming of QALYs

Answer 33

 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.)

Question 34

So why do decision makers in the uk use QALYs

Answer 34

 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

Question 35

Cost-effectiveness threshold

Answer 35

= 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

Question 36

Determining the cost-effectiveness threshold

Answer 36

 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

Question 37

Thresholds for highly specialized technologies

Answer 37

=  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

Question 38

Modifiers used by the scottish medicines consortium

Answer 38

- 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

Question 39

Which kind of rationing do we prefer?

Answer 39

‘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?’

Question 40

The Cancer Drugs Fund (CDF)

Answer 40

= 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)

Question 41

Has HTA/Economic evaluation been useful in the uk? Pros

Answer 41

- 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

Question 42

Academic's Concerns HTA/Economic evaluation

Answer 42

 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