‘Every disadvantage has its advantage’ is a saying we all know. Conversely, it also applies. For instance, a long shower and a new jumper have disadvantages for the earth. We all have a responsibility to weigh up in these. Logical. But do we make that trade-off? Do we even see it?

Take new patented drugs. They offer hope to patients, their loved ones and therefore society as a whole. Hope is positive, powerful and therefore very valuable. What is the flip side of that? That monopoly sellers can force too high prices on society. Higher than what is appropriate for the health gains it delivers, higher than a reasonable profit margin, higher than what care delivered by healthcare personnel (non-drug treatments) costs. Good for the livelihoods of these drug companies, shareholders, pension funds, tax revenues, arrival of new resources and employment. But perhaps at the bottom line detrimental to our society?

Drug manufacturers make things difficult for society when they do not respect the transparent limits it sets for affordable care. You can only spend your money once. If you spend it on one thing, you cannot spend it on anything else. Everyone knows this principle when it comes to their own pockets. For the most expensive drugs, the Health Care Institute examines whether or not it is wise to start paying collectively for a new drug: how does the price charged by the drug manufacturer relate to the health gain the drug offers society? It uses reference values for that, among other things. This should encourage drug manufacturers to offer drugs on the Dutch market within those limits. Then, in principle, drugs will be reimbursed from the basic health insurance and the manufacturer will be able to generate turnover faster. Fine for manufacturer and patient. Yet many manufacturers ask for more than the reference values. The Care Institute therefore often advises the minister to negotiate very high discounts (set X). You could say that this challenges the minister to say ‘no’. Practice shows that this is difficult.

For the drug manufacturer, it is clear that if he drops X he can start selling and the patient has access. Given the length of the negotiations, the discount the minister agrees to is presumably smaller than X are. And so we appear to be paying drug manufacturers more than our stated limits. Apparently, the lock provides more to the manufacturer, than respecting our package criteria. If drug manufacturers go beyond our limits, it is detrimental to society on two levels: 1) it forces patients to wait during negotiations, to which the minister is challenged, and 2) we cannot spend the overpayment on other care.

So every advantage has its disadvantage. Saying yes to an overpriced drug leads to health losses in society. The more people are aware of this, the more informed we can all make choices for care that is truly effective at a reasonable price. You only start seeing it when you realise it.

Margot Overgaag is senior policy officer at the Dutch Healthcare Authority. She is a member of the National Consultation on Expensive Medicines and she works on behalf of the Dutch Healthcare Authority with colleagues from the ACM and Zorginstituut Nederland on the programme Maatschappelijk Aanvaardbare Uitgaven en prijzen van Geneesmiddelen (MAUG; www.maug.nl)