Social health insurance for all residents

In the Netherlands, we have social health insurance for all residents that consists of two parts: a health insurance based on the Health Insurance Act (Zvw) for curative care and an insurance based on the Long-Term Care Act (Wlz) for long-term care. Everyone has equal access to the basic package regulated on the basis of these laws, regardless of his / her income position and also regardless of his / her age and health status. The insurance system is therefore based on mutual solidarity. In order to do justice to the mutual solidarity and to maintain support for a collectively financed insurance, it is necessary for the government to carefully consider which care is and which care is not paid for from social insurance. The choice of the government to let “the state of science and practice” determine the limitation of the Zvw insured package arises from this. The bottom line is that only care that is considered effective is part of the Zvw package.

Whether the care is covered by the health insurance is partly determined by the state of science and practice. This criterion has applied since the introduction of the Health Insurance Act on 1 January 2006 and has replaced the usual criterion from health insurance. At the time, the customary criterion only applied to general practitioner care and specialist medical care, but with the introduction of this new law it applies to all forms of care (with the exception of patient transport and welfare-related aids). 

It is very explicitly stated in the report of the Health Insurance Board No. 254 dd. November 5, 2007 that health-related medical aids must meet the criterion of state of science and practice. This is in contrast to welfare-related aids, such as aids for communication, mobility and furnishing elements for homes. Tools to be used for the treatment of incontinence, ostomy, diabetes, wound care or compression therapy must meet the stated criterion.

In the period 2006 to 2015, the Health Insurance Board – the predecessor of the current Zorginstituut – followed the principles of evidence-based medicine to determine what should be considered the state of science and practice. The practice of evidence-based medicine implies the integration of individual clinical expertise with the best evidence available from systematic research, meaning the results of valid and relevant clinical research.

In the period 2007 to 2015, the Health Insurance Board has extensively tested new medical devices such as the Ness Handmaster to ensure that they comply with the state of science and practice and has reached a position.

The medical devices already present in the package – or new variants thereof – have not been tested. Providers of medical devices, which have transferred from the coverage under the health insurance to the coverage under the basic insurance, have also not committed any demonstrable activities to comply with the state of science and practice by submitting a file with evidence, to the Health Insurance Board.

As of 2007, numerous assessments have been made (resulting in a point of view of the Health Insurance Board) with the result that parts of the working method have evolved or been further elaborated. In addition, a number of subjects have been explored in recent years, such as the interpretation of the subject “appropriate evidence”. There are also recent international developments that are connected. This refers to the so-called GRADE method. This is a new way of assessing the quality of the available evidence for effectiveness.

 

In January 2015, the updated version of Assessment of the state of science and practice is published. It describes in detail the new requirements and assessment criteria. New is the naming of the responsibilities of the health insurers.


The nature, content and scope of the insurance are insured in the Zvw
performances and health insurers are obliged to translate these into insured performances in the policies. The performance descriptions in the policies are largely described generically and the policies also contain the state of science and practice as a limitation of the claims. It is primarily up to the health insurer to decide whether a particular intervention is covered by the policy. That means the insurer in the first instance itself checks whether the requirement in the policy has been met, including the question whether the care complies with the state of science and practice. The Zorginstituut is in the position to take an unsolicited position regarding the state of science and practice (if, for example, a health insurer cannot resolve it itself or has doubts) about a particular intervention.
It must be established that health insurers have carried out the assessment in a limited number of cases and that the majority of medical devices have not been tested against the state of the art and practice criterion and are therefore potentially vulnerable in terms of whether or not they are reimbursed.

The need for these assessments was apparently not felt, or it could be that social resistance was expected. After all, until recently it was not an issue on the political agenda. Until shortly. On 20 April 2020, as a result of a broad social revaluation carried out by the Inspectorate of National Finances, the report “Towards a future-proof healthcare system” was published. Two proposed policy options are of interest to manufacturers of medical devices.

The first policy option still leaves room in time.

It is important that the cost-effectiveness of new and existing care in the package is investigated on a larger scale. Assessments on the state of science and practice is part of this. Care that does not comply will not be reimbursed (anymore).


The other policy option is much more drastic.

Medical aids, including incontinence, ostomy, diabetes products, bandages and therapeutic elastic stockings, are included in the basic package. There are no assessments anymore, it is simply going out of the reimbursement.

These and many other measures are presented as policy options to the government and parliament and are based on decisions as of September 1, 2021 and effective as of 2022. Then it is good to see how this vision is taken up socially.

The Dutch Healthcare Authority states that changes – read savings – are necessary; the Social Economic Council, which includes employers and employees’ organizations, endorses the need for changes; the social debate in the press is limited to reporting the announced changes, but does not dispute them.

In July of this year, the report of the Ministry of Health, Welfare and Sport, Care Choices in 2020, is published, which discusses matters such as central purchasing by the national government of medical devices, which will entail price negotiations. In short, assessments based on scientific and practical knowledge will be on a larger scale, if the assessment is positive, there is a chance that price regimes are imminent. And with the ultimate threat of failure to do so, we propose scrapping the reimbursement without nuance.