Out-patient drug policy by clinical assessment rather than financial constraints? The gate-keeping function of the out-patient drug reimbursement system in The Netherlands.
Since 1991, the Dutch Price Reference System (DPRS) has aimed at a growth reduction of out-patient drug costs without loss of medical quality. New drugs are excluded unless they pass legally anchored clinical criteria, i.e. substitutability with accepted drugs (DPRS-list 1a, implies a reimbursement maximum), 'unique and valuable' (DPRS-list 1b, liberal price setting), or lack of value (rejected). We analysed the performance (transparency, judgement stability) of the gate-keeping function during July 1999-July 2002. For drugs applied for DPRS-list 1b status, we relate the satisfaction of existing and implicit criteria to being accepted or rejected. Of 85 DPRS-list 1b applicants, 20 were shifted to DPRS-list 1a, 52 were accepted, and 13 were rejected with different roles of therapeutic value, budget impact, and burden of disease, the latter emerging as a decisive yet non-legal criterion. The gate-keeping function of the DPRS offers a non-opportunistic balance between clinical and economic demands, provided the burden of disease criterion is implemented, and provides influential tools for financial constraints.
Pronk
Marja H
MH
Department of Social Medicine, Public Health Epidemiology J3-313, Academic Medical Centre, P.O. Box 22660, 1100 DD , Amsterdam, The Netherlands. marja.pronk@mhpronk.nl
Bonsel
Gouke J
GJ
D017281:Cost of Illness; D016527:Drug Costs; D004526:Efficiency; D020793:Gatekeeping; D006801:Humans; D007349:Insurance, Health, Reimbursement; D009426:Netherlands; D010045:Outpatients; D012051:Reimbursement Mechanisms
Ned Tijdschr Geneeskd. 2002 Sep 14;146(37):1729-33
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