2.1 The Dutch HTA framework

The Dutch HTA-based reimbursement decision-making process basically consists of four phases: the selection phase, the assessment phase, the appraisal phase and the policy decision phase (Figure 1). Together they form a full framework for the systematic application of HTA, especially used in the context of outpatient pharmaceuticals.

Figure 1.

Phases in the reimbursement decision-making process.

The first phase is the selection phase which concerns selecting the interventions which become subject of the subsequent decision-making phases, since it is not feasible nor desirable to evaluate all new technologies. In the closed system, this selection happens systematically. New products enter this phase when the manufacturer submits an application for admission to the GVS to the MoH (de Boer and Pasman, Reference de Boer and Pasman2016). This can be done after receiving marketing authorisation from the European Medicines Agency (EMA). In the open system, selection is less systematic, for instance induced by disputes between health insurers and care providers, direct questions from the MoH or based on risk assessments of ZIN. Twenty-six technology assessments initiated by the GVS and 17 technology assessments initiated otherwise (including 10 ‘clarifications’) were published in 2018 (ZIN, 2020a).

The assessment phase starts with ensuring the selected interventions belong to the health care domain and to be potentially covered under Health Insurance Act, which can be relevant for instance when dealing with lifestyle interventions (Titlow et al., Reference Titlow, Randel, Clancy and Emanuel2000). If the intervention is deemed not to belong to the health care domain, the MoH is advised to exclude it from the BBP. Otherwise, the intervention is typically assessed on four criteria: effectiveness, cost-effectiveness, necessity and feasibility (for a detailed description, see Box 2). The assessment is mainly based on scientific literature, assuming that the literature is indicative of the real-world outcomes of the assessed intervention. For outpatient pharmaceuticals, two explicit rules exist which limit the extent of the assessment. First, when the estimated budget impact, three years after admission to the BBP, is less than €10 million per year, cost-effectiveness does not need to be assessed. That is, the criterion of cost-effectiveness is not used in cases with a ‘low’ budget impact. Five assessments in which this exemption rule was applied were published in 2018 (ZIN, 2020a). Second, typically, if pharmaceuticals do not claim superior therapeutic value than already listed products, cost-effectiveness also does not need to be considered. If equivalent therapeutic value is established, these products are clustered with similar products (in terms of indication criteria, mode of administration and targeted patients) on ‘list 1A’ of the GVS. One price limit applies to all clustered products, hence lowering the need for cost-effectiveness given that the products have a similar therapeutic value. Nine products were added to ‘list 1A’ in 2018 (ZIN, 2020a). In other cases, a full assessment is required, including cost-effectiveness. When interventions from the open system are made subject to HTA, the same process is normally followed, although the criterion of cost-effectiveness in practice often is evaluated more limitedly in these cases, which may be related to lack of information.

Figure 2.

Reference values costs per QALY.

Stakeholders, like care providers, patient associations and health insurers, are consulted at an early stage of the assessment phase to give their input. The stakeholders can also be consulted by ZIN during the assessment to obtain relevant information. ZIN moreover collects available scientific evidence. In case of outpatient pharmaceuticals or inpatient pharmaceuticals in the lock, this is done to complement the evidence submitted by the manufacturer. Frequently, available scientific evidence is generated by studies funded by the respective manufacturers (Al-Badriyeh et al., Reference Al-Badriyeh, Alameri and Al-Okka2017). After a dossier is built, the scientific advisory board (Wetenschappelijke Advies Raad; WAR) of ZIN can be consulted, in closed meetings, to assure the scientific quality of the assessment. This board consists of independent academics, clinicians and pharmacists, all appointed by ZIN. Draft versions of assessment reports are sent to stakeholders for comments.

The third phase, the appraisal phase, largely consists of the deliberations by the societal advisory board (Advies Commissie Pakket; ACP) of ZIN. The ACP consists of eight independent experts appointed by the MoH. Their fields of expertise range from clinical practice and patient representation to ethics and health economics. The ACP performs a deliberative societal weighing of the assessed criteria, combined with other aspects considered relevant for the decision, also in a societal context, like the availability of alternatives, orphan status of disease, patient vulnerability and palliative vs curative interventions. The ACP meetings are public and open to participation by external stakeholders. The minutes of these meetings are public as well. Note that not all interventions that go through the assessment phase also necessarily go through the appraisal phase. In fact, for most outpatient pharmaceuticals, this latter phase is omitted, while highly expensive inpatient drugs are more often subject to elaborate appraisal. Four appraisals were conducted in 2018, three of which concerned expensive inpatient drugs, placed in the lock (ZIN, 2020a).

During the final phase, the executive board of ZIN, based on the information obtained in the assessment and appraisal phase, formulate their advice to the MoH on inclusion in the BBP. The MoH subsequently decides, often in line with this advice. Besides direct inclusion or exclusion, price negotiations with manufacturers, coverage with evidence development (or conditional reimbursement) and arrangements with care providers aimed at the improvement of care delivery can be part of that decision. Such instruments are currently especially used in the context of expensive, inpatient drugs. The final outcome of a decision-making process is published in the Law Gazette (Staatscourant).

3.1 Closed system for reimbursement

The structure of the GVS is an important feature. It obliges both stakeholders as well as policy makers to use HTA in the decision-making process in the Netherlands. As highlighted above, the GVS forms a closed reimbursement system using a positive list. As a result, before and during the process of decision making, a new pharmaceutical is not yet reimbursed. Only after completion of the HTA process and a positive reimbursement decision, the intervention may be reimbursed and becomes available to clinicians and patients in practice. This dependency provides a strong incentive for stakeholders to contribute to a timely start and completion of the HTA process by fulfilling their roles. These roles include applying for admission, providing evidence on effectiveness and cost-effectiveness, and participating in meetings aimed at determining the scope of the HTA. In addition, the closed reimbursement system obliges policy makers to apply HTA to all submitted interventions. It moreover does not require Dutch policy makers to actively search for new interventions that could be made subject to HTA; these interventions actively present themselves through application for reimbursement by their manufacturers. Note that (the possibility of) having a closed system may also relate to the other mentioned characteristics of outpatient pharmaceuticals.

3.2 Absence of alternative policy measures

Related to the previous point is the absence of alternative policy measures to guide and control health care expenditures. Given this absence, the perceived need to apply HTA is likely to increase. Once outpatient pharmaceuticals are admitted to the BBP, no specific budgeting policies, or other policies enforcing economic considerations, are in place in the Netherlands. As a result, the consideration of the economic aspects of an intervention is formally limited to the HTA-based reimbursement decision, giving this process a unique role. As a consequence, from a policy maker's perspective, this process is positioned as an important, non-optional component of the institutional constellation when economic aspects are to be considered.

3.3 Marketing authorisation

The requirement and process of marketing authorisation is an important feature of the market for pharmaceuticals. It provides a base for HTA assessments as it produces evidence on the safety and efficacy of these health interventions (Paul and Trueman, Reference Paul and Trueman2001), as required by the EMA. Although the evidence needed for marketing authorisation does not suffice to demonstrate effectiveness or cost-effectiveness, the conducted studies and their results provide a first fundament for studies on these assessment criteria in the Dutch context. In addition to this first evidence generation, the marketing authorisation process produces standardised documentation on the pharmaceutical and its intended use, which facilitates the HTA. Moreover, a clear marketing authorisation procedure highlights the new products coming on the market, which facilitates horizon scanning and prioritising HTA research. Related, the requirements for marketing authorisation work as a hurdle, preventing interventions for which generating evidence proved unfeasible or with unfavourable characteristics from proceeding to the ‘fourth hurdle’ of deciding on reimbursement.

3.4 Identifiable and accountable counterparty

The presence of a manufacturer capable of producing the required evidence is a fourth important issue typically associated with (outpatient) pharmaceuticals. Many manufacturers have the resources to initiate and finance the studies needed to obtain evidence on effectiveness and cost-effectiveness of their products. They can be and are held responsible by policy makers to produce this evidence if applying for reimbursement in the Dutch context. These characteristics are related to market features and the proprietary nature of pharmaceuticals. A manufacturer of a new pharmaceutical is typically holder of a patent which provides the exclusive right to manufacture and market this new intervention during several years. Consequently, the expected financial revenues of reimbursement of the intervention during those years will benefit a single, identifiable entity. This entity can thus be obliged by policy makers from the start of HTA to produce required evidence for a coverage decision. This makes clear who needs to produce the evidence, which normally is an entity who is in principle capable of actually producing it. The (financial) risk of evidence gathering is thus placed outside ZIN in the Dutch context, and even outside the public domain.

3.5 Product characteristics of pharmaceuticals

Pharmaceutical interventions are often standardised products with clearly defined use and functioning, which are aimed at improving patients' length and health-related quality of life. Their effectiveness is mainly determined by the active substance, or substances, they contain. Consequently, when these products are correctly dosed, their effectiveness is relatively independent of the person administering them (Drummond et al., Reference Drummond, Griffin and Tarricone2009) or the organisational context in which they are provided. This ‘confined nature’ allows making valid and general statements regarding their effectiveness and cost-effectiveness based on clinical studies (even when conducted outside of the Netherlands), including (double) blinded randomised controlled trails (potentially even placebo controlled), and using traditional HTA methodology, including outcome measures like the QALY.

4.1 Closed system for reimbursement

In contrast to outpatient pharmaceuticals, the five other types of health technologies used here as illustration of the challenges expanding the scope of HTA in the Dutch situation are part of the open system for reimbursement in the Netherlands. Therefore, the requirement for manufacturers to apply for admission and to submit evidence on effectiveness and cost-effectiveness is not present for these types of health technologies. Consequently, policy makers are not ‘automatically’ provided with an inventory of subjects for assessment, let alone with HTA dossiers for these technologies. As a result, they will need to screen and select interventions for assessment, which requires additional effort, clear processes and rules by which to do so. Horizon scanning methods (Oortwijn et al., Reference Oortwijn, Sampietro-Colom, Habens and Trowman2018) may contribute to meeting this aim by the identification of specific technologies that need to be subject to assessment. Since 2015, horizon scanning has been performed in the Netherlands; however, this has been limited to new pharmaceuticals (ZIN, 2020b). In Canada (CADTH, 2017) and in the United Kingdom (NICE, 2020), horizon scanning has already been implemented for a broader range of health technologies (including medical devices and surgical procedures). Experiences in these jurisdictions may provide extremely valuable information to Dutch policy makers aiming to broaden the scope of their horizon scanning and, ultimately, application of HTA. The identification and selection of already reimbursed and used interventions for further investigation may require specific methodologies and processes, also because withdrawing reimbursement of already provided interventions may be a difficult and sensitive topic (van de Wetering et al., Reference van de Wetering, van Exel and Brouwer2017). In 2014, the ‘Appropriate care’ programme (Moes et al., Reference Moes, Houwaart, Delnoij and Horstman2019) was introduced by ZIN, which had as one of its aims to identify low-value care (i.e. especially ineffective or low effective care) provided in Dutch health care practice. Central to this programme is a systematic screening of the full Dutch BBP, in close cooperation with stakeholders, not limited to any type of health technology. This programme resulted in several studies and publications which pointed at potential areas for improvement in terms of the effectiveness of currently covered and provided care (e.g. ZIN, 2017b). Although not directly intended for this purpose, this programme may also help to identify already reimbursed health technologies that should be subjected to a full HTA process. Additionally, this programme may be extended to include horizon scanning for new health technologies and, as such, may offer a platform to extend the systematic use of HTA across different health care sectors and also for existing care interventions.

In addition, having an open system often involves the challenge to obtain cooperation from stakeholders in making changes in the coverage of particular health technologies. An open system does not financially incentivise stakeholders to enrol in an HTA process, also because the intervention is already reimbursed during its assessment. Hence, the only change relative to that status quo resulting from an HTA would be negative (withdrawing reimbursement). This could lead to attempts to avoid, postpone or delay the HTA process and to provide less clear evidence (if withdrawal on that basis is less likely). Expanding the scope of ‘the lock’ (Box 1), currently limited to inpatient pharmaceuticals, may be one route forward for selected interventions. This expansion may require formulating explicit criteria to select interventions to be made subject to ‘the lock’, as well as a clear indication of how the process of evidence gathering and decision making will take place for these interventions. In that context, dependency on stakeholders, especially regarding their provision of evidence, may be reduced by public funding of studies on effectiveness and cost-effectiveness, as will be discussed below.

4.2 Absence of alternative policy measures

Budget restrictions exist for each of the other types of health technologies, in the Dutch setting. Hospitals, for example, are funded by health insurers with whom they agree on budget ceilings and fixed budgets (NZa, 2019). These restrictions not only lead to a cap on total expenditures, but also require local budget holders (e.g. hospitals) to make choices about the use of these interventions, based on (for them) relevant criteria. As a consequence, on a national level, the perceived need to apply HTA may be less pronounced compared to the perceived need to apply HTA to outpatient pharmaceuticals where no such cap on expenditures exists. At the national level, this can result in a lower perceived need to systematically engage in HTA for these interventions.

A downside of these budget restrictions is that differences between care providers can occur if budget holders make different choices about the use of certain interventions. This can lead to unwarranted treatment variation across care providers and patients (ZIP code health care). Moreover, the choices made at lower levels in the health care system may not align with the principles and goals set at the central level. Put differently, the resulting use of resources may not be the most necessary, effective and cost-effective. Expanding the use of HTA may help in overcoming such differences and suboptimal decisions, but requires central decision-making bodies to perform an increased number of assessments as well as ensuring that other actors act in line with their decisions, which may require much effort and better instruments to ensure adherence to centrally made decisions or guidelines.

4.3 Marketing authorisation

For most non-pharmaceutical interventions, no market authorisation procedure is in place. This means that information regarding effectiveness and safety, as well as regarding the exact intended use of the intervention is not available at the onset of an HTA process. Medical devices form an exception (French-Mowat and Burnett, Reference French-Mowat and Burnett2012). For medical devices, a system of marketing authorisation is in place, but this is quite different from that for pharmaceuticals. Marketing authorisation requirements for devices depend on their risk class and range from providing a self-declaration (for devices with low risk) to providing clinical evidence showing that the device works as planned and is safe (for devices with high risk and without an equivalent device present in the market) (Van Norman, Reference Van Norman2016; European Parliament, 2017). Evidence on clinical effectiveness is not required for any of the risk classes. Therefore, also for medical devices, evidence on effectiveness is not available at the start of a potential HTA process. This leaves Dutch policy makers for most non-pharmaceuticals without a (systematically enforced) evidence base to start from. Information may be obtained from other sources (e.g. scientific literature generated to inform clinical guidelines), but this may be lacking, differ in form and strength, and needs to be actively collected and processed. When these sources prove insufficient, public funding of evidence generation may be required in order to enable a full HTA.

Systematic overviews of health technologies other than pharmaceuticals entering the market are likely to be absent as well, and given the lack of information about their safety, costs and effects, any type of risk-based prioritisation of which technologies to evaluate in an HTA process may prove difficult to apply. Additionally, some of the interventions, including authorised devices, may not be suitable for common types of evaluation (like RCTs). Developing methodologies and processes to scan for new or ‘risky’ interventions, also to prioritise these for HTA, may contribute to formulating solutions to these challenges. As mentioned above (see ‘Closed system for reimbursement’), broader horizon scanning for new health technologies has been implemented in some other jurisdictions, which is important to take into consideration in implementing this in the Netherlands.

4.4 Identifiable and accountable counterparty

Like for inpatient and outpatient pharmaceuticals, medical devices normally have a manufacturer who may own the exclusive right to manufacture and market a particular device. This would make them an identifiable and accountable counterparty in the HTA process similar to pharmaceutical companies. However, numerous manufacturers in this sector are small and medium enterprises (SMEs) (Kirisits and Redekop, Reference Kirisits and Redekop2013), although recent extension of marketing authorisation requirements [Regulation (EU) 2017/745, 2017] may change this situation over time. SMEs may lack the resources (financial and knowledge) to produce the evidence required in a common HTA process. This poses an important challenge, as it requires setting rules for which entities can and which cannot be held responsible for evidence gathering, and which (funding) mechanisms to apply when a manufacturer cannot produce the evidence required to have a meaningful HTA process.

For other types of health technologies, a single manufacturer may not even exist, which emphasises the importance of the issue of who is responsible for evidence gathering and starting the HTA process. Non-pharmaceutical interventions may not be patentable, and as a result, no single entity may own the exclusive right to market the intervention. As a consequence, policy makers may not have a clear counterparty to obtain evidence from or to make (price) arrangements with. In the absence of such a counterparty, both a (selectively) closed system of reimbursement and market authorisation requirements cannot ensure adequate evidence generation. Creating evidence in the absence of an accountable counterparty then logically would become a public task. This has been shown to be feasible in the Netherlands in previous research programmes (van der Sande et al., Reference van der Sande, Lamberts and Rooijmans2003; van de Wetering et al., Reference van de Wetering, van Exel and Brouwer2017), and is also the case in the current ‘Potentially Promising Care’ programme (ZIN, 2020c). This programme has an annual budget of €69 million available to provide temporary public funding for research into potentially promising interventions, which are currently not reimbursed from the Dutch BBP. Health care providers are invited to submit grant applications to this programme, not limited to specific types of health technologies. The costs of care provision can be funded, as well as the costs of research activities. However, the funding of research activities is limited to 20% of the total grant. Hence, the ‘Potentially Promising Care’ programme may be seen as an example of how to overcome the issue of not having an accountable counterparty.

4.5 Product characteristics of pharmaceuticals

Except for inpatient pharmaceuticals, each of the other types of health technologies in general differs from outpatient pharmaceuticals in terms of important product characteristics. When reflecting on medical devices, at least three important differences from (outpatient) pharmaceuticals can be distinguished. First, their outcomes may be more context-dependent: personal characteristics of the care provider and the organisational context can influence how a device is used and hence the associated costs and effects (Drummond et al., Reference Drummond, Griffin and Tarricone2009). Second, medical devices may evolve in daily practice (Rothery et al., Reference Rothery, Claxton, Palmer, Epstein, Tarricone and Sculpher2017). As a result, a device may develop during evidence collection, or the studied device might not be equal to its current version. In such contexts, research findings have a lower external validity and policy decisions may be based on outdated information. Third, learning effects in their use add to the complexity (Tarricone et al., Reference Tarricone, Torbica and Drummond2017b). The (cost-)effectiveness of an intervention may improve over time due to such individual or organisational learning effects, raising questions about for instance optimal timing of data collection. These three differences challenge the common practice of making one single decision shortly after market access. They also emphasise the importance of the ‘maturity’ of devices, which is relevant in determining when and how to evaluate the device. Alternative adaptive HTA processes (Husereau et al., Reference Husereau, Henshall and Jivraj2014) may contribute to meet these challenges. Curative interventions, mental health care interventions and non-curative care may share these differences and challenges. Additionally, they are often more ‘intangible’ as ‘products’ and demarcating them and their use may prove difficult (e.g. Blencowe et al., Reference Blencowe, Boddy, Harris, Hanna, Whiting, Cook and Blazeby2015), hampering the use of HTA and arriving at clear policy conclusions. Close cooperation with practising care providers may be necessary for their evaluation, in order to standardise the investigated intervention as much as possible. However, other challenges related to such ‘intangible’ health technologies exist as well, as described by Ergina et al. (Reference Ergina, Cook, Blazeby, Boutron, Clavien, Reeves and Seiler2009) for surgical interventions.

Among other challenges (Knapp and Wong, Reference Knapp and Wong2020), the diversity of the intended outcomes of non-pharmaceutical curative mental health care interventions adds to the methodological challenges of performing HTA in this context. More than for many other curative interventions, mental health care interventions may be aimed at improving outcomes beyond health-related quality of life of the individual patient. Intended outcomes of such interventions may include well-being, autonomy, reduced criminality or drug abuse, and social participation (e.g. Schawo et al., Reference Schawo, Bouwmans, van der Schee, Hendriks, Brouwer and Hakkaart2017). Such goals stress the need for adequate outcome measures, which may not be readily available. Moreover, using different outcome measures for these interventions may improve relevant outcome measurement while at the same time complicate comparisons across diseases and therefore decision making. Future research could further strengthen both methods as well as the policy-making process based on adequate outcome measures.

Finally, non-curative interventions, including care for the elderly and palliative care, may often be primarily aimed at improving well-being (rather than health) of care users. This focus on well-being brings specific methodological challenges. Although outcome measures aiming to capture well-being in different ways and comprising various life domains have been developed (Coast et al., Reference Coast, Flynn, Natarajan, Sproston, Lewis, Louviere and Peters2008; Netten et al., Reference Netten, Burge, Malley, Potoglou, Towers, Brazier, Flynn, Forder and Wall2012), further investigation into their performance remains needed (Hackert et al., Reference Hackert, van Exel and Brouwer2017). Moreover, a recent scoping review (Weatherly et al., Reference Weatherly, De Faria, van den Berg, Sculpher, O'Neill, Nolan, Glanville, Isojarvi, Baragula and Edwards2017) concluded that considerable disagreement exists on the question which outcomes and which outcome measures are appropriate to use in the evaluation of social care. To date, agreement on the appropriate measures to be used in these contexts appears to be lacking, which complicates interpreting and comparing the results of conducted studies in the decision-making phase. Solutions to these challenges may range from developing new instruments for outcome measurement to alternative adaptive HTA processes (Husereau et al., Reference Husereau, Henshall and Jivraj2014). Making progress on actually developing and testing potential solutions for the various challenges may be stimulated by publicly funded research programmes targeted at these issues, such as the Dutch ‘HTA methodology’ programme (Jönsson et al., Reference Jönsson, Oortwijn, Rutten and Wailoo2015) that was in place in the Netherlands in the past. It will also benefit from close cooperation between HTA methodology experts and policy makers.

4.6 Health technologies and their challenges

Using the discussed challenges, the five selected types of health technologies can be arranged according to their ‘relative distance’ in terms of number and degree of differences compared to outpatient pharmaceuticals. Most comparable to outpatient pharmaceuticals are inpatient pharmaceuticals. Differences with outpatient pharmaceuticals in the Dutch context are the open reimbursement system and the presence of alternative policy measures to control costs. As a result, new inpatient pharmaceuticals are not actively presented to policy makers by manufacturers in order to apply for reimbursement. Moreover, these manufacturers have no incentive to actively engage in an HTA process, since the default in the open system is reimbursement. Nonetheless, information on new inpatient pharmaceuticals can be easily obtained from EMA. Expanding the use of the recently introduced ‘lock’ may change this situation, but does require criteria for selecting the interventions entering the lock. It also requires efforts to perform an increased number of assessments for those interventions entering the lock. After inpatient pharmaceuticals, medical devices may be seen as closest to outpatient pharmaceuticals according to the here discussed characteristics and Dutch context. A limited marketing authorisation procedure for devices is in place and there may be a counterparty capable of supplying the evidence required for an HTA process in some cases, though certainly not all. At present, medical devices are part of the open system in the Netherlands, leading to similar problems as for inpatient pharmaceuticals. Moreover, medical devices may be less standardised, which can hamper the validity of research and the decision-making process. Hence, alternative adaptive HTA processes may need to be developed and tested (Husereau et al., Reference Husereau, Henshall and Jivraj2014; Fuchs et al., Reference Fuchs, Olberg, Panteli, Perleth and Busse2017). Furthermore, although guidance on the assessment of devices has become available (e.g. EUnetHTA, 2015; ZIN, 2015), the availability of solutions to highlighted HTA challenges for the assessment of medical devices is limited (Fuchs et al., Reference Fuchs, Olberg, Panteli and Busse2016; Blüher et al., Reference Blüher, Saunders, Mittard, Torrejon Torres, Davis and Saunders2019). Additionally, the absence of an accountable counterparty and of marketing authorisation may result in the absence of evidence for assessment, in some cases. This challenge may be met by setting rules for which entities can be held responsible for evidence gathering, combined with creating funding mechanisms for evidence generation in other circumstances. Furthermore, although fewer European member states (systematically) assess medical devices than pharmaceuticals (EC, 2017), an opportunity for European collaboration on (improving the methods for) the assessment of medical devices exists (Erdos et al., Reference Erdös, Ettinger, Mayer-Ferbas, de Villiers and Wild2019). Such collaboration may lower resources needed to perform these assessments.

The other three types of health technologies share these differences and challenges, although arguably to an even stronger degree. In addition, their product characteristics pose additional challenges. The ‘intangible’ nature of some curative, mental health care and non-curative interventions may impede demarcating specific interventions and arriving at clear policy conclusions. Furthermore, curative mental health care and non-curative interventions both may differ in their intended outcomes as compared to outpatient pharmaceuticals. This may require other outcome measures than QALYs. In the absence of agreement on such outcome measures, interpreting and comparing results may be complicated, as well as decision making based on outcomes of evaluations. Further development of methods, procedures and decision-making processes may be required. Arguably, this will be most challenging for non-curative interventions, which may be seen to have the largest distance to outpatient pharmaceuticals. The resulting order is illustrated in Figure 3, in which a larger distance from outpatient pharmaceuticals signals additional or more pronounced challenges for HTA in the Dutch context.

Figure 3.

Illustration of five types of health technologies and their relative distance from outpatient pharmaceuticals.