A Belgian cooperation platform Thomas Rousseau NIHDI - COOPAMI. Thomas Rousseau NIHDI - COOPAMI 2

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A Belgian cooperation platform www.coopami.

1 A Belgian cooperation platform Thomas Rousseau NIHDI - COOPAMI Thomas Rousseau NIHDI - COOPAMI

2 The Belgian health insurance I. Basic principles of the Belgian health insurance II. Payment mechanisms III. Financing IV. The management of the health insurance V. Summary

3 What i m not going to talk about

4 Usefull information Report of the European Observatory on Health Systems and Policies: Gerkens S, Merkur S. Belgium: Health system review. Health Systems in Transition, Websites: National Institute for Health and Disability Insurance: ww.riziv.fgov.be The B. Health Care Knowledge Centre: FPS Social Security: for questions:

5 The Belgian health insurance 1. Basic principles of the Belgian health insurance

6 The Belgian health insurance The three dimensions of universal coverage Height of coverage Breadth of coverage Depth of coverage

7 The Belgian health insurance A universal coverage (breadth: who is covered?) Almost the whole population is covered: > 99% The entitled persons: Salaried or self-employed persons and civil servants The unemployed, the retired, the disabled, student, orphans, etc. And their dependants (children, couples living together, etc.)

8 The Belgian health insurance A compulsory insurance 1. All working people have to pay social security contributions 2. All entiteld persons must affiliate with a sickness fund

9 The Belgian health insurance An equitable system based on solidarity: more than an insurance 1. Horizontal solidarity: between healthy people and sick people 2. Vertical solidarity: between rich and poor Sociale contributions are related to the income and do not depend on the health risks!!!

10 The Belgian health insurance Sector Social contributions for Salaried persons Employee contribution (%) Employer s contribution (%) Total (%) Medical care 3,55 3,80 7,35 Invalidity benefits 1,15 2,35 3,50 Unemployment 0,87 1,46 2,33 Pensions 7,50 8,86 16,36 Family benefits 0,00 7,00 7,00 Accidents at work 0,00 0,30 0,30 Occupational disease 0,00 1,00 1,00 TOTAL (= global contribution) 13,07 24,77 37,84 Source: FPS Social Security

11 The Belgian health insurance The three dimensions of universal coverage Height of coverage Breadth of coverage Depth of coverage

12 The Belgian health insurance A broad coverage (Depth: what is covered?) A very broad benefits package The services that are covered are described in the nationally established fee schedule (the nomenclature) Extremely detailed and lists more than 8000 services: consultations, visits, special technical provisions, dental care, nurse care, physiotherapy, implants, prostheses, For each service: an identification number, contractual fee and reimbursement rate Pharmaceutical products on a positive list are covered Intervention for a hospital stay or for treatment in a health care institution Excluded: Esthetic care, acupuncture, homeopathy, osteopathy, services that do not meet the reimbursement criteria

13 Nomenclature The Belgian health insurance

14 The Belgian health insurance Since 2008: no difference between salaried workers, civil servants and self-employed persons!!!

15 The Belgian health insurance The three dimensions of universal coverage Height of coverage Breadth of coverage Depth of coverage

16 The Belgian health insurance

17 In reality Height of coverage Breadth of coverage Depth of coverage

18 The Belgian health insurance 2. Payment mechanisms

19 Payment mechanisms Insured / Patient Health care provider Sickness fund

20 Payment mechanisms Insured / Patient 2 obligations: 1. Affiliate or register with a sickness fund 2. Pay social security contributions Freedom of choice: sickness fund health care provider (+ right to a second/third/ opinion)

21 Payment mechanisms Health care providers Generally organized as self-employed professionals The general practitioner : works mainly in private practice The medical specialist: can work in health institutions (mostly hospitals) and/or on an ambulatory basis in private practice Therapeutic freedom for physicians A significant proportion of health care providers are paid on a fee-for-service basis No referral system between GPs and other specialists

22 Payment mechanisms Sickness fund Private non-profit-making organizations with a public interest mission They are grouped into 5 national associations according to their political or ideological background : 1. National Alliance of Christian Mutualities 2. National Union of Neutral Mutualities 3. National Union of Socialist Mutualities 4. National Union of Liberal Mutualities 5. National Union of the Free and Professional Mutualities Their role in the compulsory health insurance system 1. Ensure the reimbursement of health-care expenses 2. Control of conformity with the legal rules (advisory physicians) 3. Provide information to their members and the health care providers The compulsory insurance package and the social contribution rates are identical for all funds Differences in complementary insurance extra premium

23 Payment mechanisms 1. A system of reimbursement Insured / Patient the full fee Health care provider certificate Sickness fund Reimbursement = Official fee Co-payment

24 Payment mechanisms 2. A system of third party paying Insured / Patient Hospital Co-payment or user charge Pharmacie bill insurance allowance Sickness fund

25 The Belgian health insurance 3. Financing

26 Where is the money coming from? Health insurance is one of the 7 branches of the Social security 3 systems of social security Salaried persons 79% Selfemployed persons 12% Civil servants 6% Its own reglementation Its own social protection Its own methode of financing

27 Where is the money coming from? Who is collecting and managing the money for the social security? 2 collecting institutions National Social Security Office (NSSO) National Institute for the Social Security of the Self-Employed (NISSE) Salaried persons and fonctionnaires Self-Employed persons

Alternative financing 66% 10,3% 23,7% Why?

contributions Salaried persons NPO National Social

resources and management of incoming funds

28 Where is the money coming from? Social contributions Government subsidies Alternative financing 66% 10,3% 23,7% Why? limit government subsidies reduce employers' contributions Salaried persons NPO National Social Security Office NIHDI Globalisation of the financial resources and management of incoming funds Distribution of financial resources between sectors according to the real needs Security PUBLIC Institutions

Where is the money going to? 0,41% 0,28% 7,06% 13,47% Expenditures of social security 2012 0,02% Total: 70.212.287.

29 Where is the money going to? 0,41% 0,28% 7,06% 13,47% Expenditures of social security ,02% Total: ,50% Medical care Sickness benefits Pensions Family benefits Accidents at work Occupational diseases Unemployment Bankruptcy 33,40% 8,86%

30 Where is the money going to? Social health Insurance expenditures 2012 (000 ) Reimbursement of health care services Internationales conventions Administration costs sickness funds Administration costs NIHDI Other expenditures total expenditures

care sectors Médecins Hôpitaux Médicaments Maisons de repos Infirmiers 9,24% Solde

31 Where is the money going to? 4,46% 3,28% 4,67% 2,70% 2,18% 2,43% 0,98% 0,17% 0,13% 0,06% 1,60% Doctors 29,09% Health care sectors Médecins Hôpitaux Médicaments Maisons de repos Infirmiers 9,24% Solde Dentistes Pharmaceutical products 17,70% Hospitals 21,31% Implants Kinésithérapeutes Rééducation Dialyse Bandagistes et orthopédistes Audiciens Opticiens

32 The long-run challenge: accommodating increasing expenditures 5 Trends in health expenditure in Belgium, ,5 4 3,5 3 2,5 2 Total health expenditure GDP 1,5 1 0,

33 Fixation of the budget How do we fix yearly the reimbursement budget of health care?

34 Fixation of the budget Health Insurance Act: Budget T-1 + Growth norm(%) + Inflation T (%) = Budget T

35 The real growth norm Fixing the annual global budget objective is therefore not subject to a vote in parliament, but the parliament can change the growth norm Evolution ,50% ,50% ,50% ,00% ,00%

36 The Belgian health insurance 4. The management of the health insurance

37 Organizational structure FPS Public Health FPS Social Security Funds NHDI NSSO Regulation Supervision NISSE Services Health care provides Health institutions Sickness funds Insured people Patients

38 NIHDI The National Institute for Health and Disability Insurance Since 1963 A public social security institution under the responsibilities of the Minister of Social Affairs (and Public Health) Extended management autonomy Management agreement Manages and supervises the compulsory health care and benefits insurance

NIHDI Preparation and realisation of public health policy The organization and financing of health care institutions The organization of health professions The emergency

Organize reimbursement of medical costs Elaborate legislation and regulation Monitor the evolution of health care spending Inform health care providers, sickness funds

39 NIHDI Preparation and realisation of public health policy The organization and financing of health care institutions The organization of health professions The emergency medical FPS Health Ministry NIHDI Public social security institution General organization and financial management of the compulsory health care and benefits insurance Organize reimbursement of medical costs Elaborate legislation and regulation Monitor the evolution of health care spending Inform health care providers, sickness funds and the insured, and to ensure they apply the legislation and regulation correctly Organize the negotiations between the different actors involved in compulsory health insurance

40 NIHDI Departments General Managment Committee CEO & Deputy CEO Internal audit Cell Communication Cell Modernisation ± 1350 staff members Cell Datamanagement Cell Expertise & COOPAMI Safety information Prevention service Health care Departement Benefits Department Medical Evaluation and Inspection Department Administrative Inspection Department General Support Departments Fund for Medical Accidents

41 Stakeholders The collective negotiation process in the health insurance Government Employers NIHDI Salaried employees and self-employed workers Health care providers Sickness funds

42 The object The collective negotiation process in the health insurance The global orientations on health policy and global budget General reglementation The reimbursed medical services the nomenclature The remboursement tariffs and fees

43 The collective negotiation process in the health insurance Negotiation bodies Minister of social affaires General management Committee for Health Care Insurance General Council Budget Control Committee Sectoral negotations Conventions and agreements commissions Preparatory negotations Technical councils Workgroups

44 The collective negotiation process in the health insurance National conventions and agreements Sickness funds Negotiations on fees and reimbursement tariffs An agreement is only possible if it falls within the budget provided for the sector involved Physicians and dentists: Agreement not into force If more than 40% of all physicians within a region have notified their refusal to adhere to it, or If more than 50% of GPs and 50% of specialists have refused to adhere to it Other health care professionals: convention into force if 60% have subscribed If no agreement or convention: government impose fees unilaterally for some or all services or set the reimbursement levels, leaving physicians free to set their own fees Health care providers

45 The Belgian health insurance 5. Summary

46 The main features of the Belgian health care system A liberal view of medicine The patient has the freedom to choose High quality care A system of compulsory health insurance system Decision making based on negotiations

47 We welcome your questions, suggestions, comments!

A Belgian cooperation platform Thomas Rousseau NIHDI - COOPAMI. Thomas Rousseau NIHDI - COOPAMI 2

A Belgian cooperation platform www.coopami.org Thomas Rousseau NIHDI - COOPAMI Thomas Rousseau NIHDI - COOPAMI 2 29-02-2012 What i m going to talk about Social security Presentation: ti only on social