title: Similarities and differences between five European drug reimbursement systems.
abstract: OBJECTIVE
  The aim of our study is to compare five European drug reimbursement systems, describe similarities and differences, and obtain insight into their strengths and weaknesses and formulate policy recommendations.
  
  
  METHODS
  We used the analytical Hutton Framework to assess in detail drug reimbursement systems in Austria, Belgium, France, the Netherlands, and Sweden. We investigated policy documents, explored literature, and conducted fifty-seven interviews with relevant stakeholders.
  
  
  RESULTS
  All systems aim to balance three main objectives: system sustainability, equity and quality of care. System impact, however, is mainly assessed by drug expenditure. A national reimbursement agency evaluates reimbursement requests on a case-by-case basis. The minister has discretionary power to alter the reimbursement advice in Belgium, France, and the Netherlands. All systems make efforts to increase transparency in the decision-making process but none uses formal hierarchical reimbursement criteria nor applies a cost-effectiveness threshold value. Policies to deal with uncertainty vary: financial risk-sharing by price/volume contracts (France, Belgium) versus coverage with evidence development (Sweden, the Netherlands). Although case-by-case revisions are embedded in some systems for specific groups of drugs, systematic (group) revisions are limited.
  
  
  CONCLUSIONS
  As shared strengths, all systems have clear objectives reflected in reimbursement criteria and all are prepared to pay for drugs with sufficient added value. However, all systems could improve the transparency of the decision-making process; especially appraisal lacks transparency. Systems could increase the use of (systematic) revisions and could make better use of HTA (among others cost-effectiveness) to obtain value for money and ensure system sustainability.
authors.affiliation: Institute of Health Policy and Management, Erasmus University, Rotterdam, Netherlands. franken@bmg.eur.nl
authors.forename: Margreet
authors.initials: M
authors.lastname: Franken
authors.forename: Maïté
authors.initials: M
authors.lastname: le Polain
authors.forename: Irina
authors.initials: I
authors.lastname: Cleemput
authors.forename: Marc
authors.initials: M
authors.lastname: Koopmanschap
mesh_terms: D003362:Cost-Benefit Analysis; D003657:Decision Making; D005060:Europe; D006291:Health Policy / Q000191:economics*; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000191:economics / Q000706:statistics & numerical data*; D007356:Insurance, Pharmaceutical Services / Q000191:economics / Q000706:statistics & numerical data*; D038622:Internationality; D015397:Program Evaluation / Q000191:economics* / Q000706:statistics & numerical data; D011787:Quality of Health Care; D012051:Reimbursement Mechanisms / Q000191:economics / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires