‘Do you have any advice for future generations?’ is the final question from my co-host, Hans Westgeest to our guest, Gabe Sonke, in our podcast ‘De Bruggenbouwers’ who, like him, is also a medical oncologist. ‘A simple piece of advice,’ says Gabe Sonke, ’if you think why do we treat people, it’s to live longer and better. If you always keep that in mind, then you have solved a lot of questions Try to have that as a guideline’.

My guideline
I work at a health insurer and part of my job consists of assessing new treatments yet to be included in the basic package, or, conversely, reassessing what is already in the package. Regularly, I also have to assess a complex authorisation request, for an individual insured person. Let me briefly explain how this works. Everything we reimburse must comply with the state of science and practice (SWP). Basically, this is just evidence-based medicine. So for my work, I have to read a lot of articles and assess the quality and outcomes of studies. Fortunately, the Healthcare Institute’s assessment framework also gives me room to include medical arguments in my decisions, such as the severity of conditions or a lack of alternatives for the patient, for example. So I look at the evidence first and then, before writing down the final conclusion and discussing it with my colleagues, I look at the medical arguments. I then ask myself two questions. The first question is: Have I taken into account the medical needs of the patient(s)? The second question is: Is my assessment also fair to other patients? And this is an important question within health insurance because you have to ensure equity. If I approve treatment reimbursement for one insured person, this treatment should also be reimbursable for other similar patients in the Netherlands.

Also, the principle of calculating cost-effectiveness for a treatment is to take into account other patients in the healthcare system. Reimbursing a drug that is not cost-effective, including a treatment that is not effective in the guideline and prescribing this treatment may affect other patient groups. This means that the decision of the package manager, health insurer, professional group or practitioner in one case can either create space for the treatment of other patients or, on the contrary, lead to displacement. After all, the healthcare budget is limited.

Christian’s guideline
Early this year, I received an app from oncologist and researcher Christian Blank: ‘If you want, I’ll show you the results of the NADINA trial confidentially sometime.’ I have known him for quite a long time. He always has great research ideas, and he talks about them so fast and enthusiastically that it is sometimes hard to keep up with him. Oh yes, and he can be super impatient. Officially, Christian had to keep the results of his study confidential and not share them with the public until his presentation at the American Oncology Congress. However, if there is a good reason, he can share this information with someone under confidentiality conditions. In this case, it seems he can’t wait to share the data with me and spar about next steps. I responded to his app that I was naturally curious and we scheduled a meeting. After seeing the results, I understood his enthusiasm and impatience. The experimental group in his study not only got shorter treatment, but their treatment outcomes were far better than what standard care offers! And guess what guided Christian? The patient! Apparently, the patient organisation was very actively involved in the study design.

Bristol Myers Squibb’s guidance
The NADINA trial is an independent study in design and conduct but was funded by the manufacturer Bristol Myers Squibb (BMS). If you look at the study design, you would be surprised that a manufacturer initially agreed to invest in such a study leading to fewer prescriptions of their product and lower revenues. Commercially, this study would not initially seem interesting for investment. But BMS realises that a treatment that is better for patients can provide a stronger market position. Furthermore, this demonstrates not only their commitment to innovation, but also their commitment to sustainable growth.
It would be nice if more manufacturers start investing in de-escalation studies, because in the long run, this could also be commercially interesting for the company, by contributing to less toxicity and possibly better treatment outcomes and strengthening its market position.

Rapid reimbursement and implementation
In my experience, new technologies that, like the NADINA trial’s patient-centred treatment regimen, are more likely to be implemented and reimbursed. Neither patients nor the healthcare system are waiting for treatments that only work in a small proportion of patients or take an unfairly long time. After all, this would lead not only to unnecessary clinical toxicity, but also to financial toxicity and time toxicity (read loss of time). A good treatment is as short as possible and at the lowest possible dose.

This month, the treatment schedule of the NADINA trial was included in the basic package after an urgent assessment by the Healthcare Institute. Such an accelerated assessment (between 15 July and 30 August 2024) does not happen often. But this treatment is not only more effective than the existing treatment, but also cheaper. The Care Institute writes in its assessment that this could lead to savings of €17.7 million a year. With 17.7 million inhabitants in the Netherlands, that means 1 euro per person that could be spent elsewhere in healthcare. It is hard not to quickly embrace a study with these results. After all, you are not only helping this patient group, but also directly helping other patient groups.

In our healthcare system, which is based on solidarity, it is therefore of paramount importance that research ideas that not only lead to better care for one patient group, but also ensure that more money is left for other patients, are enthusiastically embraced, funded and then quickly put into practice and reimbursed.

Dr S. Barjesteh van Waalwijk van Doorn-Khosrovani is pharmacist Medicines & Society at health insurer CZ. She is a member of Commissie Beoordeling Add-on Geneesmiddelen en Moleculaire Diagnostiek (CieBAG) of Zorgverzekeraar Nederland and Associate Professor in Medical Oncology and Accessibility of Medicines at Leiden University Medical Centre. She is also a member of the Horizon Scan Working Group on Haematology and Oncology of the Dutch Health Care Institute and a committee member of the KWF’s Long-term Biomarkers Programme.