Integrating public preferences into national reimbursement decisions: a descriptive comparison of approaches in Belgium and New Zealand

Christine Leopold,Christine Y Lu,Anita K Wagner

doi:10.1186/s12913-020-05152-2

Christine Leopold, Christine Y Lu + Show 1 more

Open Access

https://doi.org/10.1186/s12913-020-05152-2

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Abstract

BackgroundPublic health care payer organizations face increasing pressures to make transparent and sustainable coverage decisions about ever more expensive prescription drugs, suggesting a need for public engagement in coverage decisions. However, little is known about countries’ approaches to integrating public preferences in existing funding decisions. The aim of this study was to describe how Belgium and New Zealand used deliberative processes to engage the public and to identify lessons learned from these countries’ approaches.MethodsTo describe two countries’ deliberative processes, we first reviewed key country policy documents and then conducted semi-structured interviews with five leaders of the processes from Belgium and New Zealand. We assessed each country’s rationales for and approaches to engaging the public in pharmaceutical coverage decisions and identified lessons learned. We used qualitative content analysis of the interviews to describe key themes and subthemes.ResultsIn both countries, the national public payer organization initiated and led the process of integrating public preferences into national coverage decision making. Reimbursement criteria considered outdated and changing societal expectations prompted the change. Both countries chose a deliberative process of public engagement with a multi-year commitment of many stakeholders to develop new reimbursement processes. Both countries’ new reimbursement processes put a stronger emphasis on quality of life, the separation of individual versus societal perspectives, and the importance of final reimbursement decisions being taken in context rather than based largely on cost-effectiveness thresholds.ConclusionsTo face the growing financial pressure of sustainable funding of medicines, Belgium’s and New Zealand’s public payers have developed processes to engage the public in defining the reimbursement system’s priorities. Although these countries differ in context and geographic location, they came up with overlapping lessons learnt which include the need for 1) political commitment to initiate change, 2) broad involvement of all stakeholders, and 3) commitment of all to engage in a long-term process. To evaluate these changes, further research is required to understand how coverage decisions in systems with and without public engagement differ.

Highlights

Public health care payer organizations face increasing pressures to make transparent and sustainable coverage decisions about ever more expensive prescription drugs, suggesting a need for public engagement in coverage decisions
Daniels and colleagues have argued that “resource allocation decisions in health care are rife with moral disagreement and a fair, deliberative process is necessary to establish the legitimacy and fairness of such decisions ... the process must be public about the grounds for its decisions; the decision must rest on reasons that stakeholders can agree are relevant; decisions should be revisable in light of new evidence and arguments; and there should be assurance through enforcement that these conditions are met.” [4,5,6,7]
We describe the approaches of two countries, Belgium and New Zealand, toward adjusting existing reimbursement processes to account for public preferences

Summary

Introduction

Public health care payer organizations face increasing pressures to make transparent and sustainable coverage decisions about ever more expensive prescription drugs, suggesting a need for public engagement in coverage decisions. Health care spending is rapidly increasing in many countries, largely due to increasing pharmaceutical spending on new medications that are becoming available at very high prices to treat cancers and other chronic conditions of aging populations [1, 2]. As Degeling and colleagues described, “Patients, advocates or consumers, otherwise known as partisan groups, are often engaged as witnesses or experts on a specific matter whereas lay, nonpartisan or disinterested citizens are more frequently asked to be involved in broader policy-making decisions.” [14] Depending on a country’s health system structure and institutional settings as well as its political, societal and cultural environment and the intended purpose of the public engagement in coverage decision making, countries have chosen different processes of engagement [15, 16], ranging from deliberative citizens’ juries to large population surveys using discrete choice experiments [17, 18]

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