The (sub-) themes that emerged during the analysis of the current and potential use of economic evaluations for healthcare decision-making, as well as the experienced barriers and facilitators to the use of such studies will be discussed below, and will be illustrated by quotes.
Current use of economic evaluations
Participants generally agreed that there is a need for improving the efficiency of healthcare. The use of economic evaluations was therefore thought to be inevitable. One participant, for example, stated; “I believe that a 30% cost increase took place there [in Mental Healthcare] in just a few short years (…) Well, in that case it's definitely worthwhile to pay attention to economic evaluations. If we allow costs to keep on rising, we will soon have no schools left and no asphalt on our roads.” (MA1) Nonetheless, the current use and impact of economic evaluations in healthcare decision-making seemed to be limited. Participants generally indicated that economic evaluations were not a dominant factor in the decision-making process and that economic evaluations hardly ever impacted the inclusion or exclusion of a specific treatment in the basic health insurance package. One participant, for example, stated; “Up until now, I have had to conclude that economic evaluations do not form the deciding factor, or hardly ever, in reaching a negative package advice. We always examine cost-effectiveness, but when matters come to a head, you realise that neither the government nor society is ready to make negative reimbursement decisions on cost-effectiveness results.” (MA2).
Participants indicated that reimbursement and/or treatment decisions are typically based on the effectiveness of a treatment, rather than on its cost-effectiveness, as well as physicians’ desire to provide a certain treatment to their patients. Some participants attributed the limited use of economic evaluations to the fact that their necessity is not sufficiently recognized, both by healthcare decision-makers and the general population. As one health economist metaphorically stated; “One way or another, it's as if the water has to rise even higher before we decide that we need to build dikes." (HE1).
Even though the role of economic evaluations in healthcare decision-making was considered limited, some participants were able to provide examples of decision-making processes in which economic evaluations have been consulted. At the macro-level, for example, economic evaluations were used in the process of determining the content of the basic health insurance package, during price negotiations between the Dutch Ministry of Health, Welfare, and Sports and pharmaceutical companies, and during the implementation of a population wide screening tool. At the meso-level, economic evaluations have been used during the development of clinical guidelines and the implementation of innovations within healthcare organizations. Within healthcare organizations, however, only CBAs were used. Participants were not able to provide examples of the use of economic evaluations at the micro-level.
Potential use of economic evaluations
Participants provided various examples of decision-making processes during which the use of economic evaluations could prove to be beneficial. At the macro-level, the government could use economic evaluations to determine what expenditures, within the healthcare sector or even in other sectors, are likely to provide the best value for money. Furthermore, economic evaluations could be used during price negotiations between health insurers and healthcare providers (meso-level) as a means to generate the lowest healthcare prices possible. Other options for using economic evaluations at the macro-level include the narrowing of medical indications (e.g. defining patient groups for whom specific treatments are cost-effective and for whom they are not) and improvements in the organization of healthcare processes (e.g. decisions to shift certain treatments from secondary to primary care, and vice versa). Even though participants saw several opportunities for extending the use of economic evaluations at the macro- and meso-level, almost all agreed that there was no room for using economic evaluations in the individual patient setting (micro-level). One of their main arguments was that talking about costs would potentially disrupt the doctor-patient relationship. This is illustrated by the following quote; “Patients become very suspicious when you start talking about costs. (…) In fact, it can stand in the way of a doctor-patient relationship.” (MI4). Some participants also emphasized that improving the efficiency of healthcare ought not to be the responsibility of the individual healthcare provider. As one health economist noted; “In my opinion, the preconditions under which physicians work, that is, the financial framework that we succeed in creating with one another, are not the responsibility of individual doctors.” (HE1).
Barriers to the use of economic evaluations
Participants identified various factors that currently prevent economic evaluations from being extensively used in healthcare decision-making.
Facilitators for the use of economic evaluations
The most frequently mentioned facilitator for extending the use of economic evaluations was educating decision-makers about how to understand and interpret economic evaluations of health technologies and how to use them in resource allocation decision-making. Participants emphasized that some basic training about health economics, and economic evaluations in particular, should be included in the medical curriculum. One participant, for example, stated; “This is an aspect of training that is completely neglected, even in medical follow-up training.” (MI1) According to the participants, health economists could do their bit by presenting their results in a clearer and more understandable way. This is exemplified by the following comment; “Well, I think that perhaps the language used by health economists should be more neutral, with more layman's terms, so that it is at least clearer; they should use plainer language, especially for those who are less well educated.” (MA3) Participants also recognized the necessity of educating the general population about (the purpose of) economic evaluations in order to build the necessary public acceptance. As one participant noted; “It is often very difficult to get such abstract ideas about cost-effectiveness across and it actually demands a lot of insight.” (MA2) Moreover, financial and intellectual support was emphasized as a requirement for making the use of economic evaluations feasible and to create incentives for decision-makers to start using them. As one participant noted; “You need support for cost-effectiveness analysis, because it is not so easy” (MI4) Some participants were also of the opinion that the reliability, consistency, and transparency of economic evaluations themselves ought to be improved and that industry-funded studies should be assessed more critically. As one participant stated; “I am actually in favour of spending more money on carrying out, or improving, economic evaluations, because this would result in less bias. Because currently many of them are carried out by private manufacturers, so from that point of view, you would like a more trustworthy assessment” (MA3).