The Dutch health insurance system

The Health Insurance Act (Zvw) is a law that regulates compulsory basic insurance. Everyone who lives or works in the Netherlands is entitled to care from the basic package. The Dutch healthcare system is based on solidarity: rich and poor, young and old, healthy and ill are all entitled to the same affordable care from the basic package. Everyone contributes to this through premiums and taxes.

The set-up of the system is made with the idea that market forces can act on the prices of health care. This is done with the intend to tackle the challenge of keeping health care affordable.

Concepts and definitions

Health Insurance

Health insurance consists of two parts: the basic and the extended package. The content of the basic package is determined by law. An insured person can take supplementary insurance for care that is not included in the basic package. A health insurer can offer various supplementary insurance policies. The health insurer determines the content, conditions and reimbursements of its supplementary insurance.

Care product

Care products in this context are medical prestations that are billable to the insurer. One care products is one billable unit. Care products can be categorized into Diagnose-Behandel-Combinatie (DBC) and other care ("overige zorg").

Care activity 

Care activities (zorgactiviteiten) are the building blocks of DBCs. DBCs are a combination of care activities, linked to certain diagnoses. Care activities are registered with a numerical identifier and a description. 

DBCs 

DBCs are a package of care activities and procedures required to establish a certain diagnosis and perform the associated treatment. The package is declared as one care product, so under one declarable identifier. For a certain diagnosis different DBCs can be available. Also, diagnoses can be clustered, such that different diagnoses can be linked to the same DBC.  

DBCs are registered nationally, by the NZa, which means all hospitals will use the same DBC identifiers to declare costs. However, each hospital will make its own agreements with insurers on the pricing of DBCs. The price of a DBC is based on an average of the care and associated costs delivered for this diagnosis and treatment. This means the price for all patients with a certain diagnosis-treatment-combination, treated in the same hospital, will be the same and will be an average of the costs incurred for each of these patients.  

This DBC system prevents having to declare each individual action such as an X-ray, a blood test, or a treatment separately. Moreover, the DBC system provides an overview of the care that is provided, the associated costs and differences between hospitals.

Other care products

In addition to DBC care products, the hospital can deliver other care products, that can be declared separately from the DBC. They come in 4 categories: 

• Supplemental products; such as expensive medication, or additional IC care 
• Diagnostics performed in the first line of care (e.g., general practitioners, physical therapists) 
• Paramedical treatment and research 
• Other procedures; this includes for example genetic counseling, nursing at home. 

Care performance

A performance ("prestatie ") is in this context the delivery of a care product by the health care provider to the patient. The price of a care performance is maximized by the NZa (with some exceptions).

Care contract

Hospitals and health insurers make annual agreements about the price and volume of care products that hospitals provide to patients. The price cannot exceed the maximum prizes as determined by the NZa. The agreements are laid down in a contract, per hospital and per insurer. More and more, hospitals and health insurers choose to make contract agreements for several years (multi-year contract).

Role of the different parties

Health Insurers

• collect the premium for the basic insurance and from this they pay for all care that falls under the basic insurance.
• have an obligation to make sure care is available by purchasing care from care providers.
• have a role in keeping the premium of the basic insurance as low as possible. That is why health insurers negotiate rates with health care providers.
• The Health Insurance Act prescribes which care must be provided, but leaves open by whom and where. This is recorded by the health insurers in the policy conditions.
• determine the content, conditions and reimbursements of its supplementary insurance. Content, and conditions can vary between insurers.

Care provider/ Hospital

• provides care to patients (delivers care products to patients).
• declares the care products delivered to patients to the insurer according to the agreed rates, as described in the care contract.

Zorginstituut Nederland (ZiN)

The Zorginstituut advises the Ministry of Health, Welfare and Sport (VWS) on the content and scope of the basic package, among other responsibilities.

NZa

The price of a care performance is maximized by the NZa (with some exceptions).