The drug budget silo mentality: the Dutch case

This article provides a broad outline of developments in the Dutch health-care policy related to the costs, budgeting, and reimbursement of pharmaceuticals. In-hospital drugs costs are part of hospital budgets, whereas for the main part of costs, nonhospital drugs, no strict budget exists. The government sets a goal for the annual cost increase of nonhospital drugs, but has only limited means to enforce that goal. Two measures were implemented to reduce drug prices: a reference price system and a price law. Both measures had a modest and temporary impact on drug prices during the 1990s. In limiting the utilization of drugs, the package of reimbursed drugs has been restricted. This led to a shift from public to private costs and possible substitution of cheaper not reimbursed drugs by more expensive reimbursed drugs. An electronic prescription system was implemented to encourage rational prescription. Although 70% of the Dutch general practitioners reported to use the system, the estimated savings on drug costs appear to be modest and far less than expected. The use of economic evaluation for reimbursement decisions will increase. From 2005 onward a pharmacoeconomic study and budget impact analysis is formally required for new nonclustered drugs seeking a premium price. Furthermore, in the future the health-care insurers will get a more prominent role in limiting the costs of drugs and enhancing the efficient use of drugs within their overall budgets. Health-care insurers may choose which drugs to purchase and reimburse and they can negotiate drug prices with the pharmaceutical industry, wholesalers, and local pharmacists.