Extended possibility to innovate on the payment model for specialist care in the Netherlands

In the Netherlands, medical procedures within medical specialist care can be reimbursed via DRG or via supplementary payments called "Other care products" (Overige zorgproducten, OZPs). The codes of the list of procedure codes (Zorgactiviteiten) within the DRG package are used for coding and billing these supplementary payments. There are four categories of OZPs:

• Add-on products: add-on for intensive care, add-on medicines, supplementary payments for coagulation factors, etc.);
• Primary care diagnostics (the services that can be ordered by primary care specialist (GP) and performed within medical specialist care facilities): laboratory diagnostics, imaging diagnostics, nuclear medicine treatment, and diagnostics, etc.);
• Paramedic treatment and diagnostics (physiotherapy, speech therapy, exercise therapy, optometry, etc.);
• Other operations (hyperbaric oxygen treatment, cryopreservation of germ cells and embryos, clinical genetic research for genetic counseling, etc.).

There are different reimbursement models for OZPs:

• Some categories of the OZPs, like primary care diagnostics or paramedic treatment and diagnostics, can be billed and reimbursed separately (fee-for-service), without opening a DRG pathway;
• The other OZP categories, like an add-on for intensive care or medicines, can be billed and reimbursed only in conjunction with the DRG, on top of the DRG tariff.

OZPs may have nationally determined tariffs (for example, add-on for intensive care or cryopreservation of germ cells and embryos) or free tariffs negotiated between provider and health insurer (for example, primary care diagnostics or physiotherapy). A detailed description of conditions of reimbursement and type of tariffs for supplementary payments is provided in the DRG manual.

In 2019, a new (fifth) type of OZP was established by the Dutch Healthcare Authority (NZa) – the "optional service" (facultatieve prestatie). Optional service is a way for providers and insurers to innovate on the payment model for care, including the creation of new payment categories or replacement of existing payment categories. For example, a bundled diagnostic package was created in 2020 for diagnostics of obstructive sleep apnea instead of three previously existed separate reimbursement categories.

The "Optional service" model is only applicable to well-established care, which is currently provided as part of the Basic Health Insurance. Innovations without proven benefits cannot utilize the "optional service" pathway.

To create a new payment category, at least one provider and at least one insurance company should submit a proposal to the NZa. The NZa approves the category. After the approval, the category can be used nationwide by any providers/insurers. The tariffs for "optional services" are no determined nationally and should be agreed locally between insurers and providers.

From 2020, NZa gave the ability to create innovative payment models only to the first-line diagnostics services. In 2021, this was extended to the add-on reimbursement categories. It means that insurers and providers can agree on add-on reimbursement of some activities or devices, which are not adequately covered by existing DRG reimbursement.

From 2022, NZa expects to extend possibilities for "optional services" to the DRG segment as well.

The full details in Dutch can be found here.

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