Leon Bijlmakers and colleagues show that Citizens who are given the opportunity to reflect and interact with each other become more modest and sympathetic to health care rationing decisions. The citizen forum identified 16 criteria that participants considered relevant and acceptable for making tough choices in health care reimbursement. These criteria and the underlying values could inform Health Technology Assessment frameworks and the process of national level decision making about the benefits package of basic health insurance.

Background
Some studies in the Netherlands have gauged public views on principles for healthcare priority setting, but they fall short of comprehensively explaining the public disapproval of several recent reimbursement decisions.

Objective
To obtain insight into citizens’ preferences and identify the criteria they would propose for decisions pertaining to the benefits package of basic health insurance.

Methods
Twenty-four Dutch citizens were selected for participation in a Citizen Forum, which involved 3 weekends (autumn 2017). Deliberations took place in small groups and in plenary, guided by 2 moderators, on the basis of 8 preselected case studies, which participants later compared and prioritized under the premise that not all treatments can or need to be reimbursed. Participants received opportunities to inform themselves through written brochures and live interactions with 3 experts.

Results
The Citizen Forum identified 16 criteria for inclusion or exclusion of treatments in the benefits package; they relate to the condition (2 criteria), treatment (11 criteria), and individual characteristics of those affected by the condition (3 criteria). In most case studies, it was a combination of criteria that determined whether or not participants favored inclusion of the treatment under consideration in the benefits package. Participants differed in their opinion about the relative importance of criteria, and they had difficulty in operationalizing and trading off criteria to provide a recommendation.

Conclusions
Informed citizens are prepared to make and, to a certain extent, capable of making reasoned choices about the reimbursement of health services. They realize that choices are both necessary and possible. Broad public support and understanding for making tough choices regarding the benefits package of basic health insurance is not automatic: it requires an investment.

Publication
Increasing the Legitimacy of Tough Choices in Healthcare Reimbursement: Approach and Results of a Citizen Forum in The Netherlands.
Bijlmakers L, Jansen M, Boer B, van Dijk W, Groenewoud S, Zwaap J, Helderman JK, van Exel J, Baltussen R.