Collective constructions of ‘waste’: epistemic practices for disinvestment in the context of Dutch social health insurance

Abstract

Background Faced with growing budget pressure, policymakers worldwide recognize the necessity of strategic disinvestment from ineffective, inefficient or harmful medical practices. However, disinvestment programs face substantial social, political and cultural challenges: mistrust, struggles for clinical autonomy or stakeholders’ reluctance to engage in what can be perceived as ‘rationing’. Academic literature says little about effective strategies to address these challenges. This paper provides insights on this matter. We analyzed the epistemic work of a group of policymakers at the National Health Care Institute on what was initially a disinvestment initiative within the context of the Dutch basic benefits package: the ‘Appropriate Care’ program. The Institute developed a strategy using national administrative data to identify and tackle low-value care covered from public funds as well as potential underuse, and achieve savings through improved organization of efficiency and quality in health care delivery. How did the Institute deal with the socio-political sensitivities associated with disinvestment by means of their epistemic work? Method We conducted ethnographic research into the National Health Care Institute’s epistemic practices. Research entailed document analysis, non-participant observation, in-depth conversations, and interviews with key-informants. Results The Institute dealt with the socio-political sensitivities associated with disinvestment by democratizing the epistemic practices to identify low-value care, by warranting data analysis by clinical experts, by creating an epistemic safe space for health care professionals who were the object of research into low-value care, and by de-emphasizing the economization measure. Ultimately, this epistemic work facilitated a collaborative construction of problems relating to low-value care practices and their solutions. Conclusions This case shows that – apart from the right data and adequate expertise – disinvestment requires clinical leadership and political will on the part of stakeholders. Our analysis of the Institute’s Appropriate Care program shows how the epistemic effort to identify low-value care became a co-construction between policymakers, care providers, patients and insurers of problems of ‘waste’ in Dutch social health insurance. This collective epistemic work gave cognitive, moral and political standing to the idea of ‘waste’ in public health expenditure. Electronic supplementary material The online version of this article (10.1186/s12913-019-4434-1) contains supplementary material, which is available to authorized users.

Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review

“…Barriers to the identification of low-value care were discussed in four records,15 19 42 57 enablers in three records10 42 45 and other contextual factors in two records 15 41. Some contextual factors aligned with the four factors driving overuse that were used for the framework synthesis 19.…”

“…Three of 27 studies targeted paediatric hospitals or health services specifically 40–42. The entire continuum of care (primary care to specialist care or healthcare system) was covered by six records 19 43–47. Four of 27 records focused on practice by a specific profession or discipline40 48–50 with two records targeting practice by the allied health disciplines of nutrition50 and physical therapy 49.…”

“…Nearly half of the included studies (11 records) included an explicit definition of low-value care8 15 19 43 45 47 49 53–56 (online supplemental file 3). Some studies failed to apply the explicit definitions or key concepts of low-value care to their study methods (two records) or applied different definitions or key concepts to those explicitly stated (nine records).…”

“…The barrier from included studies that aligned with this framework was difficulty applying what were deemed ideal prioritisation criteria (ie, availability of evidence a service is ineffective or harmful, patient safety, health and cost impacts of deadoption and use of the low-value service) due to the lack of detailed information available thus the need to apply alternative criteria 15. Enablers were reported as engagement, expertise and leadership roles of an expert advisory committee from the outset of the study, which was reported as ensuring relevancy within the study context10; a Delphi method which enabled a range of expertise to be included and decision-making when working with low level or limited evidence42; and the participation of stakeholders as a means of including their knowledge and addressing trust 45…”

Broadening the application of health technology assessment in the Netherlands: a worthwhile destination but not an easy ride?

“…The identification and selection of already reimbursed and used interventions for further investigation may require specific methodologies and processes, also because withdrawing reimbursement of already provided interventions may be a difficult and sensitive topic (van de Wetering et al ., 2017 ). In 2014, the ‘Appropriate care’ programme (Moes et al ., 2019 ) was introduced by ZIN, which had as one of its aims to identify low-value care (i.e. especially ineffective or low effective care) provided in Dutch health care practice.…”