Advising on and clarifying the contents of the standard health care benefit package

Good health is precious. This is why every person in the Netherlands is statutorily insured for healthcare costs. The Health Insurance Act (Zorgverzekeringswet, Zvw) and the Long-term Care Act (Wet langdurige zorg, Wlz) describe which care this basic insurance covers. The cover provided by these two laws is referred to as the basic healthcare package.
Because these are statutory forms of insurance for which everyone pays premiums and taxes, the government must ensure that the basic package includes care that is necessary and that works. At the same time the government must ensure that healthcare is, and remains, accessible and affordable. As an independent organization in the field of determining the contents of the basic package, the National Health Care Institute plays an important role in safeguarding these requirements.

Care that works

In order to be included in the basic package, care must, above all,  be effective: evidence must show that care does what it is meant to. This is a statutory requirement. In general, care is automatically included if its effectiveness has been proven. This does not apply to pharmacy-supplied medicines. These are only included in the basic package after the National Health Care Institute has issued positive advice and the Minister of Public Health, Welfare and Sport (VWS) has converted that advice into a positive decision.

Referee

When new treatment is involved, uncertainty may exist about whether it is sufficiently effective. In such cases the National Health Care Institute acts as a ‘referee’ and issues a so-called assessment outcome. Health insurers may only reimburse such treatment under the basic insurance if the National Health Care Institute has issued a positive assessment outcome.
Assessment outcomes always involve a treatment–disorder combination. This may mean that treatment is reimbursed for one disorder but not for another, simply because the treatment’s effectiveness has not been proven for the other disorder.

Adviser

The National Health Care Institute also acts as an adviser, both regarding the basic healthcare package’s contents and the healthcare system as a whole.

Package advice

The National Health Care Institute advises the Minister of VWS on whether to include medicines in the basic package, and also about other package-related questions. In general, effectiveness is not what is open to discussion, but whether there are other reasons for querying the inclusion of certain care in the basic package. For example, care may be so cheap that people could pay for it themselves, or care may be so expensive that we may not be able or willing to pay for it collectively. Such questions are referred to as package criteria.

Package criteria

The National Health Care Institute always asks the following questions when advising on the contents of the basic healthcare package: Necessity: a. is the disease serious enough? b. is treatment so expensive that people would be unable to pay for it themselves? Effectiveness: is there evidence that a given treatment works? Cost-effectiveness: is the ratio between the costs of a treatment and its results acceptable? Feasibility: can the inclusion of a given treatment in the package be realised in practice?

System-related advice

In addition to advising on the standard healthcare benefit package, the National Health Care Institute also advises on the healthcare system as a whole, i.e. about broader subjects such as ‘mental healthcare’ or ‘long-term care’. This helps the Minister of VWS to pursue government policy by implementing and amending legislation on the basic package.

Societal support and expertise

The National Health Care Institute has an abundance of knowledge and expertise. Health care is, however, a complex field that affects  us all. This is why other parties have an important role in our assessments: medical experts, patients’ and professionals’ associations and other parties in healthcare. We consult these parties and use their input when making our assessments and forming our advice.
Two committees of external experts assist the National Health Care Institute in managing the basic package: the Scientific Advisory Committee (Wetenschappelijke Adviesraad, WAR) and the Insured Package Advisory Committee (Adviescommissie Pakket, ACP). The WAR is mainly involved in how the National Health Care Institute assesses cost-effectiveness. The ACP supports the National Health Care Institute in considerations that affect society.
This method of working ensures that we always involve knowledge from everyday practice in our advice and assessment outcomes, and that we contribute, together with our environment, to a good and well-balanced basic healthcare package.

Lock procedure for expensive innovative drugs

Due to expected high costs, the Minister of Health, Welfare and Sport (VWS) can place medicines in the so-called lock for expensive drugs (formerly refered to as ‘waiting room’ or ‘sluice’ for expensive drugs).
These products can only be accepted into the insured package after:

• the National Health Care Institute has advised on their inclusion in the insured standard healthcare benefit package and,
• if there are sufficient guarantees for responsible use and good evidence of its efficacy, and
• if the Ministry, after negotiations, can arrive at a reasonable financial arrangement with the supplier.