Although cost-containment policies in Europe are focusing increasingly on medical devices, the impact of these policies has yet to be fully investigated, particularly in cross-country settings. This paper analyses coverage, procurement, and reimbursement of three inpatient medical devices (coronary stent, knee endoprosthesis and implantable cardioverter defibrillator) in the Italian and Spanish healthcare systems. The research was carried out by reviewing published and grey literature, as well as national and regional legislation; in addition, 19 experts from hospitals and the industry were interviewed. In both countries, there has been a shift in political power from the national to the regional level. At the same time, the content of public coverage has become more explicit. A major issue in both systems is reimbursement, i.e. the rules about funding the delivery of services included in the benefit baskets. The differences in procurement and funding mechanisms create different incentives that may have an impact on the uptake and diffusion of technologies. These mechanisms, however, can only partially explain organizational and professional behaviour, as the use of technologies in both countries is mainly left to professionals who are exposed to a variety of incentives. There is limited direct and indirect guidance of national and regional authorities over the use of technologies in both countries. It is likely that the difficult search for a balance between introducing innovations, containing costs and assuring equity will require stronger regulatory action in the next future.