Reimbursement processes – An analysis of international practice models for maintaining the health benefit baskets of solidly financed health care systems

摘要

In view of increasing health care costs and budgetary problems, a systematic reimbursement decision process for medical technologies becomes an important instrument of allocation. Coverage decisions have monetary impact on patients and service providers, and at the same time they implicitly decide whether a technology is implemented and more evidence can be gained. In Austria an overall catalogue of outpatient medical care has been worked on and will need a consistent process for maintenance and further development. Within this context, international practice models of reimbursement processes and their features are analyzed so that critical success factors can be derived. Via hand search on websites and in databases, completed by a systematic literature search, application processes for reimbursement of medical interventions and associated literature has been identified. The criterion for including a country/process was the availability of English, German, or French templates/guidelines for external application. The templates were categorized according to the information domains of the EUnetHTA core model, the funding processes were analyzed regarding to phases and characteristics. The following processes have been analyzed: Australia (MSAC), Denmark (mini-HTA), Spain (GANT), Germany (G-BA, KBV innovation service), England (NICE single technology appraisal), France (HAS application form for medical procedures), Switzerland (BAG) and Austria (MEL, OÖGKK). From the 8 identified and specified country models, Germany, France and Switzerland, which are to some degree comparable to the Austrian health care system, and additionally the Austrian pharmaceutical funding process, have been analyzed according to the process phases (topic selection, assessment, appraisal, decision, implementation) and –aspects (structures, decision criteria, dealing with evidence, stakeholder involvement, communication of results, etc.).