AIHTA - Publications - Search - [Templates for reimbursement applications]

Breyer, E. (2008): [Templates for reimbursement applications]. Masters.

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Like in other countries, priority setting and consolidation of the health benefit baskets is becoming a topic of discussion in the Austrian health care system. Contributing to that, this study analyses good-practice models of maintaining the health benefit basket: it identifies processes of systematic and transparent data collection and assessment - in particular processes where the applicants are invited to provide information structured by a template. It was the aim of this study to gain an overview of internationally used templates and guidelines for coverage applications and of the experience on using them.

Via systematic literature search and hand search, templates from Australia, Denmark, Germany, England, France, Switzerland and even Austria were identified, all of them for describing information on an in-patient or out-patient medical technology as a basis for the funding decision. The templates were categorized according to focus, structure and priorities, and along the categories of the EUnetHTA core model. The funding processes these templates are part of, especially the submission phase and the assessment phase, have been analysed alongside the phases model of Hutten & al.

Brief descriptions of the basic health systems show that most countries miss a unique benefit basket relevant for all regions, all payers, and all providers. Though in most countries it is not transparent how benefit baskets are defined and which impact they have on the actually performed benefits, there is a tendency toward systematic assessment of new health technologies, nevertheless.

The legal frameworks of social health care systems generally define that only benefits should be covered which definitely are effective, necessary, and appropriate. Thus the investigated templates have some in common despite their differences in perspective and priorities.

In all the coverage submissions, clinical evidence – evidence of effectiveness and safety of the technology - is the most extensive topic. At the same time there is a general tendency to require economic data as well, mostly as a combination of cost information and epidemiologic data, both compared to an alternative technology. Cost-effectiveness calculation is not required, but welcome.

The templates are rather different regarding the organisational, social, legal and ethical aspects. It depends mainly on the perspective and the purpose of the template, if social or organisational aspects are included and of importance.

Just as the templates differ, the whole reimbursement processes differ in stakeholders, structures, in dealing with evidence and communicating the results, and in transparency of each step. Since reimbursement of medical technologies often is applied for when evidence is still missing, a number of countries implemented conditional funding.

In most processes, on the basis of the submitted information the assessment is performed – which means that a complete externalisation of the assessment is not intended. To distinguish between assessment, appraisal and political decision is common consent. Fairness of decision is given by the transparency of criteria and their weight, both defined independently from a single case, - but it is still difficult to balance between the criteria. Value judgements are still relevant in funding decisions, but mostly not documented.

Templates for funding application seem to be an improvement towards transparency and balance of interests in social health care systems, because of structuring the process and making decisions understandable and less likely to be appealed. For the applicants the templates clearly define the prerequisites for funding. As for the reimbursement processes as a whole, transparent criteria and a clear structure seem to be essential for a reliable decision making policy.

Item Type:Thesis (Masters)
Additional Information:Master Thesis IMC Krems, reviewed by: Prof. Dr. Gerhard Zednik
Subjects:W Health professions > W 100-275 Medical, dental and pharmaceutical service plans
Deposited on:07 May 2008 11:08
Last Modified:25 Apr 2020 18:43

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