Market access for medical technologies in Estonia

Reimbursement

Hospital services are reimbursed via a mix of DRG, fee-for- service and per diem payment mechanisms. The per diem payment mechanism covers basic examination, diagnosis and treatment planning, laboratory tests, and hospital stay, while the medical procedure itself is covered via the DRG (70%) and the fee-for-service (30%) payment mechanisms. Reimbursed services and tariffs for both payment mechanisms are defined in the Estonian List of reimbursed services.

If the cost of the case is too high or too low (above the higher DRG limit or below the lower DRG limit), it will be covered completely via fee-for-service. Consequently, there is a list of procedures (related to longer than average length of stay or using high cost devices) that are exempted from the DRG reimbursement and are solely reimbursed via the fee-for-service mechanism.

Estonia shares the DRG system (NordDRG) with Nordic countries, including Sweden, Finland and Norway. DRGs are determined by the combination of a procedure code (NCSP) and a diagnosis code (ICD-10). The Estonian version of the NCSP nomenclature and the Estonian version of the NordDRG system are maintained by the Estonian Health Insurance Fund (EHIF) and are released annually.