A medical specialist in an MSB is only an entrepreneur for income tax if they run real and substantial risks. Since 2015 the hospital bills the insurer for the care. That removed the specialist's bad debt risk. They must compensate for this with other business risks, such as investing in equipment, employing staff or other financial risks.
An MSB (medisch specialistisch bedrijf) is a medical specialist enterprise: the organisation in which a hospital's independent specialists work together and with which the hospital contracts. The MSB can be a partnership, or a cooperative in which the specialists or their companies are members.
In short
- Through integrated funding, specialists lost their own billing right in 2015 and with it, in principle, their entrepreneur status for tax (House of Representatives, 2016 evaluation).
- According to the government, real and substantial risks include investing in equipment, hiring staff or otherwise running financial risks. The overall picture decides.
- In March 2026 the NZa saw insufficient progress on four of eight improvement points for MSBs. That monitor may play a role in a decision on salaried employment for specialists.
In this article
- Why is a specialist in an MSB not automatically an entrepreneur?
- What are real and substantial risks?
- Which MSB models exist, and what do they mean for your tax?
- What does entrepreneur status bring, and what if it is missing?
- Does the tax authority still look at this?
- What is happening around the MSB in 2026?
Why is a specialist in an MSB not automatically an entrepreneur?
Because since 2015 the hospital receives the full payment from the insurer. The specialist no longer bills and no longer runs a bad debt risk. The government wrote that specialists thereby lost "in principle their entrepreneur status for tax purposes" (Evaluation of tax aspects, annex to parliamentary paper 32012, no. 39).
According to the Ministry of Finance, the remaining risks are then "as a rule of too little importance" to conclude that someone is an entrepreneur for tax. For doctors working in one hospital, making no investments and bearing no staff costs, doing nothing was not an option (Appendix to the Proceedings, House of Representatives 2014/15, no. 3323).
The MSB itself was an unforeseen result of the reform. Research in five Dutch hospitals describes the MSB as a fiscal entity representing all self-employed physicians in a hospital (Ubels and Van Raaij, 2023).
What are real and substantial risks?
The government gave three examples: investing in business assets such as equipment, hiring staff, or otherwise running financial risks. Those risks must have real and substantial significance. According to the government this follows from case law (Appendix to the Proceedings, House of Representatives 2014/15, no. 2586).
It is about the overall picture. Anyone scoring lower on one point can compensate with another. Not all features of entrepreneurship weigh equally (no. 2586). The same test applies to specialists as to other entrepreneurs (Evaluation of tax aspects).
The tax authority sets out that general test. It looks among other things at profit, independence, capital, the number of clients, visibility to the outside world, business risk and liability for debts (Belastingdienst, When are you an entrepreneur for income tax? (in Dutch)).
Which MSB models exist, and what do they mean for your tax?
Specialists and hospitals worked out two models: the cooperation model and the participation model. Each model can be fiscally transparent or non-transparent. Four questions were involved: the position for income tax, the obligation to withhold payroll tax, the VAT exemption and the corporate income tax exemption (Evaluation of tax aspects).
In a transparent model, such as a partnership, the specialist can remain an entrepreneur if conditions are met. Their entrepreneurship must then be evident from other factors (no. 2586). Where parties could not compensate for the loss of the billing right, they mostly chose a non-transparent model: a cooperative (no. 3323).
A cooperative pays corporate income tax. The healthcare exemption in corporate income tax does not work if the members are directly or indirectly natural persons, the tax authority's knowledge group ruled in a case about a GP cooperative (KG:211:2025:2, 3 April 2025).
What does entrepreneur status bring, and what if it is missing?
As an entrepreneur you are entitled to business tax facilities. In 2026 the self-employed deduction is € 1,200 and the SME profit exemption is 12.7%. The 2027 Tax Plan proposes a self-employed deduction of € 900 in 2027 (2027 Tax Plan bill). That remains a proposal until the vote in the House of Representatives on 12 November 2026. More on this in 2027 Tax Plan: what changes for entrepreneurs.
If you are not an entrepreneur and not employed either, you have income from other work. Profit is calculated the same way, but you are not entitled to schemes such as the self-employed deduction or the investment deduction (Belastingdienst).
The MSB or the hospital also has a stake in this. The obligation to withhold payroll tax was one of the four questions in choosing a model (Evaluation of tax aspects). If there is in fact an employment relationship, the principal must withhold payroll tax.
Does the tax authority still look at this?
In 2016 the government wrote that hospitals and specialists who had not consulted the tax authority in advance were "in any case on the tax authority's radar". Depending on signals, tax returns and other findings, the tax authority would act (Evaluation of tax aspects).
No more recent public source on how the tax authority assesses specialists' entrepreneurship in 2025 or 2026 has been found. So no new policy is known. The test remains the overall picture of all circumstances, and that can change from year to year if your arrangements with the MSB change.
What is happening around the MSB in 2026?
On behalf of the Ministry of Health (VWS), the NZa monitors whether MSBs are improving enough. According to the second interim report of 9 March 2026, there is sufficient progress on four of the eight improvement points. Lagging behind are the MSB's financial transparency, deciding jointly on hiring independent specialists, merging into one MSB per hospital, and agreements without stronger production incentives (VWS, decision memo on the monitor, 3 March 2026).
The monitor stems from an agreement to make salaried employment compulsory for medical specialists if there is insufficient improvement. VWS calls the monitor relevant for the justification of such a measure. In addition, an amendment by the House of Representatives asks for € 150 million in savings on medical specialists' pay (VWS, decision memo, 3 March 2026). No decision on compulsory salaried employment is known as at 1 November 2026.
How hospital and MSB work together varies widely. In the study of five hospitals, the contract between hospital and MSB played no role in the day-to-day relationship in any case, and most incentives were financial penalties (Ubels and Van Raaij, 2023).
- Record each year which risks you bear yourself: investments, staff, income risk, liability.
- Check the MSB's membership and cooperation agreement for fixed payments without risk.
- If in doubt, submit your situation to the tax authority in advance.
Sources
- House of Representatives, Evaluation of tax aspects, annex 1 to parliamentary paper 32012, no. 39, 6 July 2016 (in Dutch). officielebekendmakingen.nl
- Appendix to the Proceedings, House of Representatives 2014/15, no. 2586, answers to parliamentary questions on the entrepreneur status of medical specialists (in Dutch). officielebekendmakingen.nl
- Appendix to the Proceedings, House of Representatives 2014/15, no. 3323, answers to parliamentary questions on tax advice for MSBs (in Dutch). officielebekendmakingen.nl
- Belastingdienst, When are you an entrepreneur for income tax? (in Dutch), accessed 1 November 2026. belastingdienst.nl
- 2027 Tax Plan bill, 15 September 2026, table of income tax parameters (in Dutch). rijksoverheid.nl
- Tax authority knowledge group, KG:211:2025:2, Does the healthcare exemption apply to Cooperative X? (in Dutch), 3 April 2025. kennisgroepen.belastingdienst.nl
- Ministry of Health, Welfare and Sport, decision memo on the cover letter for the Monitor of improvement potential of medical specialist enterprises, interim report 2, 3 March 2026, House of Representatives 2026D10547 (in Dutch). berthub.eu (copy of House document)
- Ubels, S. & Van Raaij, E. M. (2023). Alignment in the hospital-physician relationship: A qualitative multiple case study of medical specialist enterprises in the Netherlands. International Journal of Health Policy and Management, 12, 6917. doi.org