Prof. Dr. Alain De Wever (ULB)
PLAN PL AN Belgium I. II. Cost of health III. Financial resources IV. Health organizations V. Evolution of the healthcare in the world VI. Healthcare environment in Belgium VII. Conclusion
11,000,000 INHABITANTS 3 REGIOS VL / W / Bxl 3 COMMUNITIES VL / Bxl – W / Germans
II. II. Cost Cost of health th 2012 Reimbursement Authorities (INAMI) : à healthcare 25,627 million € à work compensation 6,244 million € Patients 8,050 million € Private insurance 1,800 million € Ministry of Social Health (Hospitals) 1,824 million € Financing H.I. 1,215 million € Administration reg & local communities 1,500 million € Federal administration 3,500 million € TOTAL 49,760 million €
Health th expen expenses ses (INAMI 2009-2012 – – budget t 2013) 2009 2009 2012 2012 Budget t 2013 Médecins 6. 637.649 7.265.430 7.538.422 Infirmières 984.311 1.177.618 1.280.262 Dentistes 733.995 804.462 841.457 Pharma 4.120.388 4.366.572 4.250.645 Kinés 549.049 624.859 657.250 BMF 4.505.495 5.180.920 5.509.247 Forfaits 195.657 237.478 260.151 Dialyse 359.719 404.042 434.274 MRS 2.062.415 2.483.905 2.594.303 MAF 304.212 328.002 372.949 TOTAL TOTAL 22.421.800 22.421.800 24.077.384 24.077.384 26.676.58 26.676.586
III. Fin III. Finan ancial Resou cial Resources rces 2/3 BISMARCK 1/3 BEVERIDGE
IV. Health th organizati tions University hospitals 7 Regional hospitals Ambulatory polyclinics with specialists GP’s Ambulatory nurses : - independent - organizations Nursing homes
V. V. Ev Evoluti tion of of health thcare in in th the wo world
Changes in th the hospita tal environment t } Decrease of the growth in the healthcare expenses } Ageing population } Considerable therapeutic means } Decrease of the uncertainty in diagnosis and treatment } Decrease of the expenses for hospitalized patients/Total healtcare expenses
Changes in th the hospita tal environment t } The hospital keeps too many hospitalized patients } Decrease of the number of acute beds per 1000 inhabitants in 15 years
VI. Health thcare environment t in Belgiu Belg ium Freedom Choice for the patient Therapeutic choice for the phsyician Quality is guaranteed by : Ø ISO norms Ø CE marking Ø Drug registration Ø Medical professsion RD 78 Ø Patient rights
VI. Health thcare environment t in Belg Belgiu ium Need to rethink primary healthcare A. Need to rethink hospital care B. Need for a status for HAH C. D. Palliative care in Belgium
A. Need to rethink primary healthcare } The development of alternatives at home have already been recommended for different groups of patients (e.g. chronic patients, diabetic patients, the eldery and persons with mental death disabilities) } There is a need to develop skills (training) and tools (decision support and IT tools) to promote the implementation of a care plan (based on the evidence, patient oriented, for the whole team, and including social needs) and the work within a multidisciplinary team } KCE KCE
A. Need to rethink primary healthcare } To improve care coordination, it is recommended to further develop and streamline coordination structures and networks as well as coordinating functions } The role and responsibilities of all professionals should clearly be described. } Networks with other specialized services, including hospitals, should be developed to ensure the continuity of care. } In case of emergency/acute episode response, the role and responsibilities of all professionals should clearly be described. KCE E
B. Need to rethink hospital care HOSPITALS LAW FROM 1963 Public 30% Private non for profit 70% Agreement planning – criteria – duties Financing by state health insurance on pathologic basis medical fees by act
B. Need to rethink hospital care Acute beds too much C, D lack of integration Chronic beds shortage G Geriatrics S Revalidation MRS Nursing homes MR Geriatric homes lack of alternatives Lot of pilot projects in HAH
C. Need for a status for HAH } HAH initiatives can be seen as a way of providing care in the least complex environment that is clinically appropriate } Current HAH initiatives should be submitted to an official recognition process, granting them a license to operate. The recognition norms should ensure that minimum requirements for safety and quality of care are met } The fact that current HAH initiatives does not fall under the national planning for hospitals increases the importance of redesigning the health care lansdcape and the necessity to plan care on the basis of population needs that would hold not only for hospitals but also for primary care and transmural care
Wh What at are th the problem problems to to org organ anize ize H HAH ? ? } Lack of professionals o GP o Nurses o Hospital pharmacists 24 h/24 h } Lack of recycling in primary care training for complex home intervention } Need for specific skills delegation of tasks already for diabetics and wound care } Need for financial incentives
What Wh at are th the problem problems to to org organ anize ize H HAH ? ? } Need for a list of primary healthcare specialists possessing the appropriate skills } Case manager o legal status o lists of care ressources o patient electronic medical record Quality assurance procedures } Necessary to avoid overlapping with existing coordination structures
What Wh at are th the problem problems to to org organ anize ize H HAH ? ? } Multidisciplinary teams o x 2 care pathways diabetes renal failures o home oxygen therapy o palliative home team o multidisciplinary oncology consultation (MOC ) Ø Need o a common plan roles and responsibilities of each o collaboration of specialists for complex care o communication o empowering the patient
Wh What at abou about futu ture fina financ ncing ing ? ? } The FFS payment system needs to be adapted to achieve an adequate remuneration of health professionals differentiated according to the level of qualification (in particular for nurses) and the workload. The payment system should also enable to develop holistic approach in patient care. The latter involves payment for the coordination of care, quality insurance as well as education of the patient and the informal caregivers.
Wh What at abou about futu ture fina financ ncing ing ? ? } Financing mechanisms between the different settings should be more neutral for similar care modalities. This may require to improve the data available on true cost of an intervention in different settings. The possibility to provide financial incentives or disincentives) to optimize the choice of the best clinical setting could be analysed.
What Wh at abou about futu ture fina financ ncing ing ? ? } The financing of HAH activities in Belgium will depend on the definite choice on the nature of the medical activity that will be performed in HAH and will need to be integrated in the larger scope on the future reform on the hospital financing.
What Wh at abou about futu ture fina financ ncing ing ? ? } According to previous Belgian reports, the introduction of a mixed financing system could be considered, with the following possibilities : for pre/post care and acute care, a DRG system for the whole episode of care based on real cost (which implies data collection and the determination of homogene groups in terms of resources consumption) for the remuneration of some specialized services or expensive pharmaceutical and medical devices, a fee-for- service system with adequate tariffs (KCE)
D. Palliative care in Belgium Definition 1. History 2. Location 3. Financing 4. Teams 5. How many specialized beds ? 6. Summary 7. What about quality ? 8.
1. De Definiti tion IN BELGIUM LAW 14/6/2002 LAW 14/6/2002 Global care with multidisciplinary approach for the best quality of life in autonomy
2. 2. Histo tory 3 Ways Home Care From 1980 Nursing Homes Hospital Pilot experiences - Aremis - St-Jan Hospital (Brussels) From ‘90 - 3 Federations ( W – VL – Bxl)
2. 2. Histo tory 19/8/91 - 1st RD Health Insurance Financing for experimental solutions home care hospital From ‘95 - Holiday for palliative care From ‘97 - Development of financing for home residential hospital - platforms RD meeting with all professionals in a regio 25 in Belgium
2. 2. Histo tory From ‘98 - Home teams agreed by RD From ‘99 - Palliative forfait at home paid by the health insurance 2000 - Training in nursing homes 2002 - Law 2005 - Day Centers
3. 3. Locati tion } Home multidisciplinary team } Nursing home specialized nurses } Hospital specialized wards teams in the different wards
4. 4. Fin Finan ancin cing } No financial contribution by the patient } Forfait /home/nursing home ü (data) form made by GP to health insurance ü 647,16 € (2 times maximum) } Holidays (1 month) } Hospitals } Medical fees } Nursing fees
5. Team 5. Teams } Home/Nursing home coordination centers } GP } Nurse } Psychologists –physiotherapist } Familial support
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