What’s your dissertation about?
“I’ve researched how healthcare actors decide which new treatments are funded within their public healthcare system. Which treatments are covered by the basic health insurance package? And which criteria are adopted in this context? What’s important is that the choices made actually contribute to an efficient and equitable disbursement of the healthcare budget. In the Netherlands, this efficiency is determined on the basis of cost-effectiveness and to which extent the decision does justice to patients’ burden of disease.
“For example, we recently gained a new treatment for a rare disease that costs 1.9 million euros per treatment. The question at that point is whether this treatment should be paid from taxpayers’ money. As a country, our touchstone for determining whether costs should be considered prohibitive is the burden of disease. The worse shape a patient is in, the higher we’re prepared to set this limit. An infected toenail shouldn’t cost too much, in other words. I’ve also examined whether this policy reflects equity considerations found in society, and which relation there is between these considerations and the patients’ burden of disease and age.”
What were your main conclusions?
“There’s considerable support for linking a treatment’s cost-effectiveness to a patient’s burden of disease. But what people may well find even more important is that cost-effectiveness is viewed in relation to the patient’s age. In other words, people find it important to take on board both how ill someone is, and how old. Even though in the Netherlands, age is explicitly ruled out as a criterion for patient selection – we have ethical objections. But there’s still a relationship between the method used for calculating the burden of disease and age: in reimbursement decisions for elderly patients, this burden is given a higher relative weighting.
“So one of my conclusions is that you will have to do something with these preferences – by incorporating them in your decision-making framework, for example. And even when you don’t feel the need to accommodate public opinion – giving every patient the same level of access to care – you would have to correct the current calculation model for burden of disease, since right now it discriminates in favour of older patients.”
Could you draw lines between your research and the debate regarding which target group should be prioritised in the Covid pandemic?
“You could make that comparison – although in the case of the pandemic, it’s not a question of which treatments should or shouldn’t be reimbursed, but who – in the event of absolute shortages – should receive medical care first. A ‘bedside decision’, in other words, while my dissertation deals with decisions at the health insurance level. When the ‘black scenario’ (shortage of beds) came up in the Covid debate, Minister Tamara van Ark made no bones about it: ‘We’re not allowed to discriminate on the basis of age: each life is equally valuable.’ This has been a point of discussion between physicians and the government.”
I read in your acknowledgements that you didn’t actually plan to pursue a doctorate?
“That’s right. I’d been working some nine years as departmental manager for a mental healthcare institution, in the child and adolescent psychiatry unit. I did art school and have a degree in Educational Theory, so the original idea was that I would study Health Care Management at EUR to gain a firmer theoretical footing.
“During the pre-master’s, I was working on a quantitative research assignment, and a whole new world opened up. I liked it so much. I discovered that I could embark on a completely new career: learning and discovering new things.
“Around the same time, I discovered that heath care management wasn’t really my thing. So before it was too late to stop, I switched to the Health Sciences research master’s, with a specialisation in Health Economic Analysis. I hadn’t rounded that off yet when I was accepted for this doctoral research position, at which point I quit my old job. The first person I thank in my acknowledgements is my former manager, for always supporting me, making it possible for me to switch programmes and giving me the opportunity to attend this programme.”
And what was it like to obtain your doctorate?
“Very special. I feel quite sorry for colleagues who are starting during the current pandemic, because I really enjoyed working together with other candidates, discussing what you run into. You’re all going through the same process. And ESHPM is a supportive environment, where colleagues help each other – that was very nice too.”
So a bed of roses all round?
“Of course you always have ups and down. One week, your article can get accepted for publication; the next week, you’re rejected for a conference. Or you’re stuck in your research, or in a flow, and this process can recur with each new study. And of course, you have to put in the hours. You can confer with colleagues, but at the end of the day you have to do it yourself. Fortunately, I’m a bit older than most, and fairly independent. But if you’re younger, you may find it a rather demanding experience. Is that bad news though? I rather liked it, since it provided opportunities to work on other things I enjoyed. I was also given a lot of scope to do projects on the side. Apart from having all the articles in my dissertation published, I was able to write eight other papers.”
