Although cost-effectiveness in healthcare is becoming increasingly important, the Netherlands has not yet set a ‘cut-off point’ setting the maximum acceptable price for prolonging a life by a year. Maarten Postma, Professor of Pharmacoeconomics at the University of Groningen, is arguing the case for more transparency.
‘The United Kingdom makes it very clear: treatment is cost-effective or efficient if it costs less than 30,000 pounds to prolong a life by one year. Anything above this figure is not. This refers to ‘quality adjusted life years’, which are years calculated according to the quantity and quality of life lived. In the Netherlands, pharmaceutical companies must be able to prove that their new drugs are not only effective and safe, but also that they are cost-effective. However, our country does not have a cut-off point. No-one is prepared to stick their neck out, which is why our system is somewhat unclear.’
‘The Healthcare Insurance Board, which is the body that makes recommendations about reimbursement for drugs, requires an analysis of cost-effectiveness when a company applies for the right to reimbursement. This analysis must be carried out according to specific guidelines. If you compile a satisfactory analysis, you will have proved efficiency, no matter how expensive the drug may be.’
‘This now resembles a ritual dance around the quality of the economic analysis. It’s ludicrous to expect manufacturers to spend so much time making an analysis of cost-effectiveness when we cannot adequately interpret the results. Similar cost-effectiveness analyses are compiled for recommendations made by the Health Council of the Netherlands, for example.’
‘It is obviously impossible to put a price tag on a life. However, in practice, we shall have to start setting boundaries to make sure our healthcare remains affordable. Making choices is unavoidable. This applies to the cost of medication, as well as to other expensive aspects of the healthcare service. We are currently making these choices implicitly; many people already have an idea of where the cut-off point is. A few years ago, a cut-off point of €80,000 was proposed in the Netherlands, which is very high in international terms. In Belgium, for example, the limit is €50,000 and in the US, it’s $50,000.’
‘If a particular drug is not cost-effective, it may still be eligible for reimbursement. There will always be exceptions; a cut-off point isn’t set in stone. Debate about the cut-off point is still raging in Great Britain and exceptions are common, for example in the field of oncology.’
‘Setting a cut-off point will certainly create more clarity about the cost-effectiveness of specific drugs. And it has consequences. You could, for example, make stricter demands regarding the proven benefits of a drug that is known to be less cost-effective. Or you could be more lenient with other aspects of drugs that are highly cost-effective. After all, the budget impact is just one of many different aspects explored during a health technology assessment.’
‘It is not easy to predict the precise implications of introducing a cut-off point for the availability of interventions and the cost of healthcare. More research is needed. And a cut-off point would not be feasible for certain treatments. Take drugs for rare diseases that affect very few people, such as Pompe disease or Fabry disease. A pharmaceutical company must be able to recoup its investment. Transparency in the development costs is essential.’
‘Of course, we would ultimately prefer transparency from manufacturers regarding all drugs. Many of the new drugs coming onto the market are ‘biologicals’, such as monoclonal antibodies. They are often very expensive, as they are difficult to manufacture and require huge investment. I would like to see this substantiated, but fear of competition makes firm figures difficult to come by.’
‘It is also important not to restrict the cost-effectiveness analysis requirements to drugs, but extend them to cover the healthcare system as a whole. In a period of increasing demand, we must be sure to make optimum use of our resources. A cost-effectiveness analysis can help us to make the difficult choices involved, as long as we use it consistently and interpret the results correctly.’
Maarten Postma is Professor of Pharmacoeconomics in the Faculty of Mathematics and Natural Sciences at the University of Groningen. He is an expert in the economic aspects of drugs (development, usage and cost-effectiveness). His research is part of the Groningen Research Institute of Pharmacy. Postma sits on various relevant advisory committees, including the Committee for Pharmaceutical Help (advice on reimbursement of drug costs) and a number of Health Council of the Netherlands committees (including Vaccination strategies in the 21st century).
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