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72 Special Solidarity Fund KCE Reports 133
System of
reimbursement
Who decides on
reimbursement of
medicines? / Parties
involved?
Table 11: Overview of extramural and intramural reimbursement
Intra muros
Extramural Intramural
Reimbursed to the patient under the
Drug reimbursement system (GVS–
Geneesmid-delenvergoedingssysteem)
GVS has 3 annexes:
- Schedule 1A: medicines for which an
alternative exist that is 100 %
reimbursable. Maximum limit of
reimbursement/patients has to pay
an absolute amount.
- Schedule 1B: medicines that are
100% reimbursable.
- Schedule 2: medicines which require
an authorisation for (partial of full)
reimbursement
College of Health Insurers (CVZ-
College van Zorgverzekeraars) advises the
Government on therapeutic value and cost
of medicines
Dutch Government- Minister of Health
finally decides on the adoption of
medicines on the list of Drug
Reimbursement System
Costs are charged on the hospital general budget,
not to the patient.
Compensation arrangements: hospitals are extra
compensated by health insurers for specific
medicines and under specific conditions under:
- Policy Regulation on ‘Expensive Drugs’
- Policy Regulation on ‘Orphan Drugs’ (only
academic hospitals)
Step 1: Framework set by the supervising,
independent Dutch Healthcare Authority
(Nederlandse Zorgautoriteit):
- Members of Health Insurers
- Members of Healthcare Providers
Step 2: Bilateral negotiations between:
- Health Insurers
- Healthcare providers
Exception: College of Health Insurers also advises
the Dutch Healthcare Authority on the adoption of
medicines within the policy regulations ‘Orphan
Drugs’ and ‘Expensive Drugs’
The costs for (orphan) Drugs that are given to patients intra muros, are charged on
the hospital budget. Hospitals are compensated by the health insurers for the medicines
they are prescribing, based on negotiations between both parties. The framework, in
which negotiations on compensations and budget between hospitals and health insurers
take place, is designed and supervised by the Dutch Care Authority (Nederlandse
Zorgautoriteit), a non-governmental, independent board that takes up the role of
supervisor and regulator of the healthcare market in the Netherlands.
Because the expensive (orphan) drugs, prescribed intra muros, laid a heavy burden on
the budget of hospitals in the past, compensation arrangements (beleidsregels) have
been concluded between the health insurers and healthcare providers, applying for
specific medicines and under specific conditions. The (partial) compensation of hospitals
by the health insurer is based on an ex-post calculation. Two compensation
arrangements are relevant from the perspective of rare disease:
• Policy Regulation on Expensive Drugs CI-1087, 1st of January 2009: under
this policy regulation, hospitals will be compensated for a registered drug
by the health insurer, if the estimated total costs correspond to 0.5% or
more of the total medicines expenditure of hospitals at macro-level. If this
condition is being met, a hospital will be reimbursed 80% of the costs,
based on a ex-post calculation.
• Policy Regulation on Orphan Drugs CI-1043: only applying to academic
hospitals: academic hospitals are eligible for compensation, if the total
costs of an orphan drug are estimated to exceed 5% or more of average
total medicines expenditure of academic hospitals. If this condition is
being met, the health insurer will fully (100%) reimburse the costs of the
orphan drugs on top of the regular budget