Abstract
Fully or partially withdrawing the reimbursement of healthcare interventions that are currently being used and reimbursed in the healthcare system but that are unsafe, ineffective or do not provide value for money (i.e. disinvestment) may contribute to the efficient allocation of the healthcare budget. However, disinvestment decisions have been perceived
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as challenging. Specific mechanisms and considerations may be at play, affecting the perceived difficulty and the feasibility of these decisions. Therefore, the objectives of this thesis were 1) to obtain insight in the mechanisms and considerations that are relevant in disinvestment decisions, and 2) to investigate aspects affecting the feasibility of disinvestment decisions.
Chapter 2 describes a qualitative interview study that showed that the outcome of disinvestment processes is affected by the contextual factors support from the public and stakeholders, institutional role and financial interests of stakeholders, the organizational skills of patient groups, and the possibility to relieve the consequences of disinvestment for current patients. No evidence was found of a consistent role of the formal Dutch reimbursement criteria in disinvestment processes.
In Chapters 3 and 4, four distinct societal viewpoints on the disinvestment of healthcare interventions were identified, each supported by approximately half of Dutch citizens, that differ on their support for disinvestment and on the considerations that are found relevant in disinvestment decisions. Common aspects considered relevant by those holding the different viewpoints are transparency of decision-making and medical necessity of the concerned healthcare intervention. Resistance to disinvestment may partly be explained by the consequences of disinvestment citizens anticipate to experience themselves as well as by not considering the increase in healthcare expenditure a large problem.
Chapter 5 describes a review of the available evidence on the disparity between willingness-to-accept (WTA) and willingness-to-pay (WTP) for healthcare goods and services. In this review, we found that to compensate for the disinvestment of healthcare interventions, 1.58 to 1.86 times higher savings are required compared to the amount of money that people are willing to pay to reimburse these healthcare interventions in the first instance, indicating that loss aversion may play a role in disinvestment decisions.
Chapter 6 describes a participatory value evaluation (PVE) on the relative importance of attributes of healthcare interventions in the context of disinvestment in the Netherlands. This PVE showed that Dutch citizens prefer to disinvest those healthcare interventions with limited to no health gain and that are targeted at patients of older age. Furthermore, it shows that citizens prefer smaller savings over larger savings.
Finally, Chapter 7 concludes that contextual factors are most important in disinvestment decisions. However, this large role of contextual factors may result in unfair differences between patient groups. The consistent and transparent application of a well-considered assessment framework for disinvestment decisions may increase the fairness and acceptability of disinvestment decisions. Furthermore, making citizens aware of the displacement resulting from not disinvesting a healthcare intervention my increase the feasibility of disinvestment decisions. Nevertheless, disinvestment decisions will remain difficult, even when it concerns healthcare interventions with limited health effects.
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