International comparison of systems to determine entitlements to medical specialist care: performance and organizational issues

E.A. Stolk*, A.A. de Bont, M.J. Poleij, S. Jerak, M. Stroet, F.F.H. Rutten

*Corresponding author for this work

Research output: Book/ReportReportProfessional

Abstract

Objective
CVZ has asked us to provide a comparison of criteria and procedures that different countries use to determine entitlements to medical specialist care. This question was asked within the context of the recent introduction of the DBC (diagnosis treatment combinations) system as an alternative to existing methods
of financing of hospital services.

Methods
The analysis covered priority systems in nine countries: Australia, Belgium, Canada, France, Germany, the Netherlands, Sweden, Switzerland, and the UK. To meaningfully compare existing criteria and procedures of different countries and analyze the possibilities and limitations of priority setting systems, we used an
analytical framework for international comparison recently developed by Hutton and co-workers (Hutton et al., 2006). The framework was created to encompass the many aspects of fourth hurdle systems. It can deal with the legal and political characteristics at the system level and the detailed nuances of varying
assessment and decision-making procedures at the decisional level. It analyses priority systems at two levels:
1. Policy implementation: the establishment of the fourth hurdle system as a policy decision of the
government, the policy objectives of the system, its legal status, and its relationships with the
remainder of the health system, with other public sector bodies, and with other stakeholders, such as industry and patient groups;
2. Individual technology decision: the processes by which individual technologies are dealt with by the system, for example, assessment processes, how decisions are made, and how they are implemented. Our analysis of international policies further contained three case studies. We selected three medical services that were assessed recently: deep brain stimulation (DBS) for Parkinson patients, transurethral microwave therapy (TUMT) for patients with an enlarged prostate and position emission tomography (PET). To reconstruct the way in which the decisions about reimbursement were made, we analyzed the assessment reports and interviewed physicians, representatives of the medical industry, and policy makers by telephone. The aim of these case studies was to analyze how the formal decision procedures are put into practice, by reviewing the nature of powers of different stakeholders who are involved, strategies to settle debates or resolve problems for example when evidence is inconclusive.

Results
The study provided an in-depth view of reimbursement procedures in the nine countries. Below we summarize the details of the procedures in the different countries.
Original languageEnglish
Place of PublicationRotterdam
PublisherInstitute for medical Technology Assessment/instituut Beleid en Management Gezondheidszorg
Number of pages193
Publication statusPublished - 2008
Externally publishedYes

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