Working Towards Legitimacy in Decision Making: on ogoverning appropriate medicine use and reimbursement in health care

In the last three decades governmental policy in prioritization of medicines is increasingly legitimized through the scientization of the decision-making process on the one hand and a separation in policy production and policy execution on the other. The discourse on health care reimbursement decisions has likewise been dominated by increased rationalization and formalization of the decision-making process. Since the early 1990s the Dutch government and arm’s length agencies have undertaken much effort to regulate pharmaceutical care, mainly by emphasizing the role evidence should have in decision-making on the appropriate use of medicines at all levels, from decisions on insurance schemes coverage to prescriptions at the point of care (Commissie Dunning 1991; Gezondheidsraad 1991; College voor zorgverzekeringen 2007). The Dutch government has developed a series of tools to promote rational prescribing – such as professional guidelines authorized by state agencies, real-time monitoring systems and the conditional reimbursement of medicines – aimed at improving the quality and efficiency of care, and enabling the control of pharmaceutical health care expenditure (College voor zorgverzekeringen 2005; Niezen et al. 2007). Despite the rationalisation of decision-making, governmental policymakers still experience difficulties in explaining the foundations for their decisions. Moreover, the execution of the health regulations in daily practice appears to deviate substantially from the intended policy and its underlying principles (Niezen et al. 2007). The Dutch drug reimbursement system is based on a bureaucratic system logic; if rational decision criteria are used, consistent and legitimate decisionmaking has taken place. The definition of formulary lists (medicines eligible for funding) presumes that appropriate medicine use and reimbursement not only can be defined, but subsequently can be implemented in health care provision. Thus, when health care providers prescribe medicines according to the national formulary, appropriate drug use is warranted. However, there is a discrepancy between the decision-making process outcomes and actual practice of medicine prescription and reimbursement. This discrepancy points at potential legitimacy problems which require further research. What work practices can be observed that are supposed to lead to (more) legitimate decision-making? And, if legitimate decision-making can be observed, how does that wear off in clinical practice? Increasing the legitimacy of prioritization decisions might decrease the difference between policy and practice. Making use of a social scientific perspective this thesis analyses the (development of the) infrastructure of the Dutch drug reimbursement decision-making process and health care allocation instruments in order to gain insight in the practice of health care prioritization decision-making and the way this is legitimized.

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