What influences the outcome of active disinvestment processes in healthcare? A qualitative interview study on five recent cases of active disinvestment

Abstract

Background Recent attempts of active disinvestment (i.e. withdrawal of reimbursement by means of a policy decision) of reimbursed healthcare interventions in the Netherlands have differed in their outcome: some attempts were successful, with interventions actually being disinvested. Other attempts were terminated at some point, implying unsuccessful disinvestment. This study aimed to obtain insight into recent active disinvestment processes, and to explore what aspects affect their outcome. Methods Semi-structured interviews were conducted from January to December 2018 with stakeholders (e.g. patients, policymakers, physicians) who were involved in the policy process of five cases for which the full or partial withdrawal of reimbursement was considered in the Netherlands between 2007 and 2017: benzodiazepines, medication for Fabry disease, quit smoking programme, psychoanalytic therapy and maternity care assistance. These cases covered both interventions that were eventually disinvested and interventions for which reimbursement was maintained after consideration. Interviews were transcribed verbatim, double coded and analyzed using thematic analysis. Results The 37 interviews showed that support for disinvestment from stakeholders, especially from healthcare providers and policymakers, strongly affected the outcome of the disinvestment process. Furthermore, the institutional role of stakeholders as legitimized by the Dutch health insurance system, their financial interests in maintaining or discontinuing reimbursement, and the possibility to relieve the consequences of disinvestment for current patients affected the outcome of the disinvestment process as well. A poor organization of patient groups may make it difficult for patients to exert pressure, which may contribute to successful disinvestment. No evidence was found of a consistent role of the formal Dutch package criteria (i.e. effectiveness, cost-effectiveness, necessity and feasibility) in active disinvestment processes. Conclusions Contextual factors as well as the possibility to relieve the consequences of disinvestment for current patients are important determinants of the outcome of active disinvestment processes. These results provide insight into active disinvestment processes and their determinants, and provide guidance to policymakers for a potentially more successful approach for future active disinvestment processes.

Under careful construction: combining findings, arguments, and values into robust health care coverage decisions

“…The Dutch media discussed both cases briefly [ 49 , 50 ]. Both cases were revisited decisions and were already in the basic benefits basket, but this status was now questioned [ 12 ]. Given this history, these are cases where decision makers are likely to have constructed the decision especially carefully.…”

“…Articulating links is the primary method for connecting elements into decisions [ 18 , 19 ]. The decision report always contains a variety of formalised criteria and case-specific considerations [ 12 , 31 ]. Links are constantly made in deliberations.…”

“…In addition, some authors are advocating “evidence-informed evaluation of [previously] identified [stakeholder] values” [ 5 , 6 ], while others work on integrating and accounting for value plurality [ 7 ]. Moreover, a growing body of literature establishes the impact of additional, non-formalised or ‘contextual’ factors on these decisions, often noting inconsistencies in the use of formalised criteria [ 8 – 12 ] (10.1016/j.healthpol.2012.09.012). In short, many heterogeneous elements may be present in the decision making and the public report.…”

“…S/he generally follows the advised decision but sometimes deviates from it [ 35 ]. The cases both concern a decision that needed to be revisited (for different reasons) and thus are likely to be relatively carefully made [ 12 ]. This analysis results in several recommendations for policy and research.…”

Withdrawing or withholding treatments in health care rationing: an interview study on ethical views and implications

“…The active disinvestment decision to withdraw treatments due to a lack of cost-effectiveness has proven to be a delicate issue [ 25 ]. If policymakers are to make active disinvestment decisions to cope with the increased financial scarcity caused by increased costs for new treatments, then it is important to have public support for such decisions [ 2 , 26 ]. Unfortunately, previous research has indicated that the public does not support treatments being withdrawn due to relative scarcity.…”