Given the necessarily limited healthcare resources and high healthcare expenditure, especially in the field of rare diseases and oncology, the introduction of a new cost-intensive health intervention may result in fewer available resources for other interventions and consequently, decisions have to be made between different interventions. In democratic societies, these decisions require not only the fundamental trust in the legitimacy of the responsible institutions (ministry, social security, health funds) but also the legitimacy of the decisions themselves by exposing the rationalities (principles and criteria) of these prioritisation decisions. In favour of equal access to medical services, often there are deliberative decision-making processes that seek to make public (health policy) decisions fairly, transparently, and evidence-based. The aim of the present study was to prepare a basis for discussion of a standardised, central process in favour of transparent decisions on expensive hospital drugs in Austria.

In a multi-stage approach, firstly the reimbursement processes (only for original preparations) in individual selected countries as well as in Austria were investigated. Secondly, the strengths and weaknesses of the elaborated processes were analysed based on predefined criteria, following the concepts of “Accountability for Reasonableness” (A4R) and “deliberative decision-making”. Thirdly, scenarios for an Austria-wide uniform reimbursement process for hospital drugs were developed.

Three scenarios were identified: The first scenario is the pilot project “Evaluation Board for Medicines in Hospitals” that follows the existing reimbursement process of the outpatient sector in Austria. The second scenario represents the roll-out of the Styrian Medical Innovation Board (MIB). The third scenario depicts a process based on the “Extra Medical Services” (MEL) process for non-drugs including the development of a special fund for high-priced drugs.

In line with the concepts of the A4R and deliberative decision-making, a transparent, evidence-based, fair and efficient allocation of existing (limited) healthcare resources to justify (difficult) decisions on priorities in democracies seems indispensable. With regard to the derivation of options for action from international processes, the transferability of these processes to the Austrian context or the pragmatic feasibility of certain options for action within the existing Austrian framework conditions needs to be reflected. The present study is intended as a basis for further discussion.