Societal views in the Netherlands on active disinvestment of publicly funded healthcare interventions
Rotteveel, A. H.; Reckers-Droog, V. T.; Lambooij, M. S.; de Wit, G. A.; van Exel, N. J.A.
(2021) Social Science and Medicine, volume 272
(Article)
Abstract
Objectives: To obtain public support for the active disinvestment (i.e. policy decision to stop reimbursement) of healthcare interventions, it is important to have insight in what the public thinks about disinvestment and which considerations they find relevant in this context. Currently, evidence on relevant considerations in the disinvestment context is
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limited. Therefore, this study aimed to explore the societal views in the Netherlands on the active disinvestment of healthcare interventions and obtain insight into the considerations that are relevant for those holding the different views. Methods: A Q-methodology study was conducted among a purposively selected sample of citizens (n = 43). Data were collected in June and July 2019. Participants individually ranked a set of 43 statements broadly covering the issues that participants could consider relevant in the disinvestment context, from ‘least agree’ to ‘most agree’. Qualitative feedback on the statement ranking was collected from each participant using a questionnaire. Principal component analysis followed by oblimin rotation was used to identify clusters of participants with similar statement rankings. These clusters/factors were interpreted as distinct viewpoints using the factor arrays and qualitative questionnaire responses of participants. Results: Four viewpoints were identified. People holding viewpoint I believe that reimbursement of necessary healthcare should be maintained, irrespective of its costs. People holding viewpoint II agree with viewpoint I, although they believe that necessity should be objectively determined. People holding viewpoint III think that unnecessary, ineffective and inefficient healthcare should be disinvested. People holding viewpoint IV, consider it most important that disinvestment decision-making processes are transparent and consistent. Conclusion: Insight in the distinct viewpoints identified in this study contributes to a better understanding of why it has been considered difficult to obtain public support for disinvestment of healthcare interventions, and can help policymakers to change their approach to disinvestment to increase public support.
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Keywords: Considerations, Disinvestment, Health technology reassessment, Mixed methods, Q-methodology, Reimbursement, Societal viewpoints, The Netherlands, Health(social science), History and Philosophy of Science
ISSN: 0277-9536
Publisher: Elsevier Limited
Note: Funding Information: This research was funded by the strategic research programme RIVM ( S/133005 ), a research fund from the National Institute of Public Health and the Environment, the Netherlands . Funders had no role in the design of the study, its conduct, or the analysis of the results and were not involved in manuscript preparation or submission. Funding Information: Similar to people holding viewpoint I, people holding this viewpoint believe that the reimbursement of necessary care (i.e. treatments that are medically necessary or are the only treatment option available) should be maintained (#24, +4; #15, +4*), irrespective of its costs (#38, +3*): ?Care should be accessible to everyone, especially if it is medically necessary.? (ID-07) However, they believe necessity should be objectively determined and not, for example, based on insufficient scientific evidence (#9, ?4*) or patient opinion (#18, ?3): ?Most important is if the treatment does not work after thorough study.? (ID-21) Furthermore, they believe that if quality of life remains low after treatment (#3, +2*), if providers have not earned back their investment (#43, ?3), and if people can pay for their own treatment (#20, +2*) reimbursement may be stopped: ?The costs of care are so high that the premium system should be changed. Wealthy people can then pay more and the socially disadvantaged can pay less.? (ID-21) Hence, they believe that in some situations, denying patients treatment is not morally wrong (40, ?4*). Furthermore, what is distinguishing for this viewpoint, is the importance attached to public support for disinvestment decisions. If there is no public support for stopping the reimbursement of healthcare, reimbursement should be maintained (#30, +3*): ?Everyone is entitled to care if there is no support [for stopping reimbursement].? (I08) Also distinguishing for this viewpoint is the importance attached to participation in society and protecting vulnerable groups in society: when treatment contributes to patients being able to participate in society (#28, +3), or if stopping treatment would affect a vulnerable group (#36, +2), reimbursement should be maintained. For further reference, we call this viewpoint ?Maintain necessary healthcare, if objectively determined and if there is no support for disinvestment?.There are several similarities between the findings of the three previous studies on relevant considerations in the context of disinvestment and some of the viewpoints identified in our current study. For instance, in our current study, we found that people holding viewpoint 4 consider it important that disinvestment decision-making processes are transparent and consistent. This seems to confirm the finding of Bentley et al. that citizens consider it important that disinvestment decisions are based on clear and consistent principles (Bentley et al., 2019) and the finding of Coast et al. that people consider it important that disinvestment decisions are transparent (Coast, 2001). Furthermore, some of the relevant considerations identified by Street et al. (2015) are supported by some of the viewpoints identified in our study. For instance, taking costs and effectiveness into account in disinvestment decisions is supported by viewpoints 3 and 4. Moreover, taking the availability of alternative treatments into account is supported by viewpoints 1 and 2. However, it becomes clear from our current study that these considerations are not supported by all viewpoints, indicating that it is important to take heterogeneity in citizens? viewpoints into account.In the Netherlands, the National Healthcare Institute uses the four criteria effectiveness, cost-effectiveness, necessity and feasibility to advise the Ministry on the reimbursement of healthcare interventions. With regards to investment decisions, effectiveness is a ?knock-out? criterion (Zwaap, 2017). However, our study shows that support for effectiveness as a criterion for disinvestment decisions varies. People holding viewpoint 1 consider effectiveness relatively unimportant, while people holding viewpoint 2 rank these considerations in the middle of the sorting grid, and people holding viewpoints 3 or 4 consider effectiveness relatively important. A similar pattern can be observed for the cost-effectiveness criterion: people holding viewpoint 1 or 2 think cost-effectiveness should not play a role, while people holding viewpoint 3 or 4 consider this criterion important. However, there seems to be some consensus on the importance of the medical necessity criterion: statement 15 on medical necessity is located in the most agree tail of the distribution for all viewpoints (+4, +3, +2, +4). Nonetheless, there seem to be some differences between the viewpoints on the consequences this criterion should have: people with viewpoint 1 or 2 generally do not see a lack of medical necessity as a reason to disinvest an intervention or service, while people holding viewpoint 3 or 4 indicate that non-necessary care should be disinvested. Furthermore, from the factor arrays some differences with regards to the interpretation of medical necessity can be observed. For instance, people holding viewpoint 2, 3 or 4 generally do not agree with taking the patient's opinion on necessity into account (statement 18), while people holding viewpoint 1 are more open to this. Moreover, while people holding viewpoint 3 think that treatments for illnesses that are part of normal life should be disinvested (statement 19), people holding viewpoint 4 do not agree with this (as this cannot be determined in a clear-cut way) and people holding viewpoint 1 or 2 are more neutral with regards to this statement. Finally, there is no consensus on the relative importance of the feasibility considerations budget-impact and public support, included in this study. Viewpoint 3 and 4 support the use of budget-impact as a criterion in disinvestment decisions, while viewpoint 1 does not support this and viewpoint 2 is neutral. Furthermore, viewpoint 2 considers public support very important, while viewpoint 1 does not seem to have a strong opinion on this and viewpoint 3 and 4 do not consider it to be important.This research was funded by the strategic research programme RIVM (S/133005), a research fund from the National Institute of Public Health and the Environment, the Netherlands. Funders had no role in the design of the study, its conduct, or the analysis of the results and were not involved in manuscript preparation or submission. Publisher Copyright: © 2021 The Author(s)
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