Health Technology Assessment and Health Care Reimbursement in the European Union: Permissive Dissensus and the Limits of Harmonization through the Backdoor

Member states have consistently limited the European Union's competences in the area of health care reimbursement. Despite these efforts, there has been a slow but steady tendency toward harmonization of a key tool in reimbursement decision-making: health technology assessment (HTA), a multidisciplinary evaluation of “value for money” of medicines, devices, diagnostics, and interventions, which provides expert advice for reimbursement decisions. This article examines the origins of this paradoxical appetite for harmonization as well as of the dissensus that has, at the moment, somewhat stalled further integration in HTA. It finds that the prointegration neofunctionalist “permissive dissensus” is still present in decision making on HTA but potentially offset by dissensus or outright opposition from key actors, including member states and the medical device industry. These actors are able to decipher the potential consequences of highly technical issues, such as HTA, for national systems of social protection. Despite that, they have little interest in politicizing the issue, potentially opening the door to integrative policy solutions in the future.

Developing Transparent Health Care Reimbursement Auditing Procedures

The continued computerization of health care records has enabled easier sampling and analysis of large sets of medical records, making it easier than ever for Medicare, Medicaid and other private insurers to use statistical audits to determine and demand return of alleged overpayments to health care providers. However, there are sometimes statistical difficulties with the audits, and there is frequently not sufficient transparency in the procedures or their application to reproduce the results in order to determine whether they have been carried out correctly. This paper addresses concerns in sampling and analysis of data records by looking at the case of a specific audit of a medical practice carried out by a private insurer. If done properly, statistical audits can be a very useful tool, but often the methodologies are vague and the implementation is either wrong or not explained fully enough to reproduce and analyze.