Market access for medical technologies in the Netherlands

Reimbursement

All specialist (inpatient, day case, ambulatory) care within the same Major Disease Category (MDC) provided within a certain period (for most services – 120 days; for surgical procedures – 42 days) is covered via a single DRG payment.

The payment system consists of the following components:

Diagnosis-related groups

• DRGs are determined by the combination of a procedure code (zorgactiviteit) and a diagnosis code. The procedure coding nomenclature and the DRG system are maintained by the Dutch Healthcare Institute (NZa) and released annually
• Around 30% of DRGs have their maximum tariffs determined at the national level by the NZa. The reimbursement tariffs for other DRGs are negotiated between individual hospitals and insurance companies

Supplementary payments – “other care products” (OZPs)

• Specialist services not reimbursed via DRG (as a stand-alone payment or in addition to the DRG payment), are referred to as the so-called “other care products”, OZPs
• The OZPs are determined by the NZa as a part of the DRG package. There are five categories of OZPs, the key ones being Supplementary Products (reimbursement for expensive medication, stay in the ICU, on top of the DRG tariff), First-Line Diagnostics (diagnostic imaging and IVD tests, reimbursed on a fee-for-service when requested by a General Practitioner), and Optional Services (allows healthcare providers and insurers to create novel payment categories for well-established care)

The DRG system is approved annually.

Specifics for IVD tests

In-vitro diagnostic tests provided in specialist settings are covered by the DRG tariff for the continuum of care. In-vitro diagnostic tests are reimbursed on a fee-for-service basis only if requested by a primary care physician (via the OZP mechanism).