Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

76 Special Solidarity Fund KCE Reports 133
Since the reform of the healthcare and insurance system, there have been many cases of
disputes between patients, hospitals, insurance providers, pharmaceutical companies and
the government with respect to the reimbursement of expensive pharmaceutics or
treatment for life-threatening diseases. The Dutch Authority of Health Insurers, the
entity that advises the Ministry with respect to the reimbursement of pharmaceuticals,
registered 1.206 disputes in 2004, in comparison to 772 disputes in 2003.
Pharmaceutical companies started seven legal proceedings against the Dutch state in
order to have some ‘expensive’ pharmaceutics adopted by the reimbursement system
for pharmaceutics.
Regarding rare diseases, it is relevant to mention the Steering Committee Orphan
Drugs (Stuurgroep voor Weesgeneesmiddelen), which was established in 2001 in order
“to encourage the development of orphan drugs and to improve the situation of
patients with a rare disease, especially to strengthen the transfer of information on rare
diseases”.
Keypoints Netherlands
• The Dutch health insurance system distinguishes three components:
statutory health insurance for exceptional medical expenses, covering a wide
range of chronic and mental healthcare services with an exceptionally high
cost; statutory basic health insurance, providing a standard benefits package;
and complementary health insurance, covering less vital healthcare services
that are not covered by the standard benefits package.
• With the 2004 reform of the healthcare system, the Dutch government
introduced a so-called ‘regulated competition’ among health insurers, based
on the idea that competition among health insurers (but also among
healthcare providers) would decrease healthcare expenditure and result in a
more cost-efficient healthcare provision. As the healthcare providers and
insurers are operating in a system where they have to negotiate with each
other on price and content of medical care, the role of the Government has
evolved towards supervision and setting frameworks.
• Health insurers in the Netherlands are private actors and are allowed to
make profits. With respect to the standard benefits package, they are bound
by acceptance obligations, which means they cannot refuse patients or
patient groups as becoming their clients. In exchange for the acceptance
obligations, the Dutch government compensates the risks that health
insurers face of having a higher number of risk patient groups in their clients
through a risk compensation system, or “risicovereveningssysteem” in
Dutch. The definition and categorization of risk patient groups is not
explicitly limited to rare diseases, but is broadly defined to all costly chronic
diseases.
• The distinction between healthcare provision intra muros (within the
hospital) or extra muros (outside the hospital) is utmost relevant regarding
the reimbursement of medicines.
• Costs for (orphan) drugs that are given to patients intra muros, are charged
on the hospital budget. 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). Specific compensations arrangements (beleidsregels) have
been concluded between the health insurers and healthcare providers,
applying for specific medicines and under specific conditions. Two
compensation arrangements are relevant from the perspective of rare
disease: the Policy Regulation on Expensive Drugs CI-1087 (for all hospitals)
and Policy Regulation on Orphan Drugs (only for academic hospitals).