SYSTEM. Ri DE RIDDER Chief Executive of the Health Care Department NIHDI

Transcription

1 BELGIAN HEALTH CARE SYSTEM Ri DE RIDDER Chief Executive of the Health Care Department NIHDI 1

2 The Belgian health insurance is a system of reimbursement fees Doctor, dentist, physiotherapist, wheelchair,... patients Affiliation Reimbursement = fee - PATIENT S CONTRIBUTION Health insurance funds 2

3 System of third party paying Insured people/ p patients Patient s contribution tib ti Health care providers Health insurance funds 3

4 HISTORICAL FACTS 1945: introduction of social security and compulsory health care insurance for workers 1963: basic law and establishment of NIHDI : changes in management and introduction of a system of financial responsibility : successive reforms in order to make NIHDI more accessible and sustainable 4

5 NIHDI: Organizational chart ral gement Gene Mana General Management Committee Sector Manageme ent General Council Committee for Health Care Insurance Management Comitee Wage-earners Management Comitee Self-employed persons Committee Department for Administrative control General Support Departments Adminis stration Health Care Department Department for Invalidity Benefits Department for Medical Evaluation and Control 5

6 1. Administrative i ti organization REGULATION Federal Public Services: exercising the art of healing hospital legislation (hospital budget, accreditation standards, planning) medicines marketing authorization & drugs/medical devices policy (through Agency) Other public health issues NIHDI: Management of the health care insurance 6

7 1. Administrative i ti organization REGULATION (2) NIHDI (continued) financial management of the system administrative organization of the system support provided during consultation process development of databases granting special provisions 7

8 1. Administrative organization REGULATION (3) NIHDI STRUCTURE Management bodies: General Board (Government, workers, employers, mutualities) Insurance Committee (mutualities, health care providers) Insurance bodies: Conventions and agreements commissions Technical boards 8

9 1. Administrative organization REGULATION (4) NIHDI STRUCTURE (continued) Scientific bodies: Scientific Board for Chronic Diseases National Board for Quality Promotion Assessment Committee for Drug Prescription 9

10 1. Administrative organization EXECUTION MUTUALITIES reimbursement to all persons insured negotiating prices and fees (collectively) information 10

11 1. Administrative organization CONTROL Mutualities NIHDI Administrative control Medical evaluation and control (reality/conformity and overconsumption) Mutualities Control Body 11

12 2. Entitlement t Starting from 1/01/2008, there is only one scheme with the same risks covered for all entitled persons and their dependants The scheme covers active and nonactive people p and their dependants. The main insured members are entitled to health insurance on the basis of their current or previous profession. 12

13 2. Entitlement t The main entitled persons have the right to health care only if contributions have been paid and equal a minimum amount (i.e. contributions paid on a minimum wage of 4.162,47 47 for employees below 21 years and 5.549,96 for employees of 21 years and over). The contribution can be in the form of social security contributions or personal payments. If the main entitled person has the right to health care, his dependants will have that same right also. 13

14 3. Funding SOURCES OF FUNDING Social contributions ti (through h social security NSSO) employers (3,80 % of the salary) workers (3,55 % of the salary) State subsidies and taxes (VAT) Specific contributions, such as Insurance companies Pharmaceutical industry 14

15 3. Funding Flux Social Contributions NATIONAL LEVEL Public Health Social Affairs State contributions, taxes, VAT, Supervision National Office of Social Security Regulation NIHDI 3rd party payer system Mutualities transfers Reimbursement Services, regulation, supervision Funds Health care provides Direct payment Services Insured people (patients) Regulation Health promotion SUBNATIONAL LEVEL Communities and regions 15

16 3. Funding Year 2010 In billions of In % Global management ,7 VAT / Excises ,9 Contributions pensioners and others 864 3,1 Insurance companies 733 2,6 Taxes on pharmaceutical products 255 0,9 External transfers 479 1,7 Others 30 0,

17 Estimated composition of the public financing of the Belgian health system 2009 (in million ) Own receipts Transfers from general scheme Transfers from self-employed Total Social contributions Subsidies Alternative financing Allocated receipts Divers (66,3 %) (10,4 %) (13,7 %) (5,8 %) (3,7 %) Total (100,0 %) 17

18 Some important data from 2007 with regard to Belgian health care expenses (Source : FPS Social Security and NIHDI) TOTAL HEALTH CARE EXPENSES ,3 (in millions of ) GDP = ,80 Mio EUR 9,8%GDP Private Public , ,90 Out of pocket 6.226,80 Reimbursements ,30 through security social Insurances 1.627,20 Through NIHDI ,40 (excl. Soc & fisc MAF + regul 171,90) Through Mutualities 889,30 In pharmacies 2.340,70 18

19 3. Funding Expenditure Health care budget of the NIHDI ,3 billion ,3 billion ,4 billion ,5 billion ,6 billion ,4 billion ,1 billion ,2 billion 19

20 3. Funding Source : OECD Health Data Version: October 2009 Total health expenditure (US $) per capita Public health expenditure as % of as % of GDP, 2007 / Belgium 2007 total health expenditure, 2007 % GDP % % BE 10,2 100 % 72,3 NL 98* 9,8 107 % 74,8 FR % 79 DE 10,4 100 % 76,9 UK 8,4 83 % 81,7 CZ 6,8 45 % 85,2 US % 45,44 * Exclusive investment 20

21 Figure 1. Total health expenditure expressed as % of GDP in selected OECD countries,

22 Figure 2. Total health expenditure expressed per capita (US$ PPP) in selected OECD countries,

23 3. Funding RESOURCES OF THE MUTUALITIES Budget : distribution based on» real expenses (70 %)» risk profile (30 %) Accounts : in case of a surplus or deficit, the insurance carriers can keep part of the surplus or they have to cover part of the deficit (max 25 % and limited to 2 % of the budget share) 23

24 4. Coverage WHICH PROVISIONS ARE COVERED? Preventive and curative care mentioned in a nomenclature (consultations, ti visits, it special technical provisions, dental care, nurse care, physiotherapy, implants, prostheses, equipment, ) mentioned on the positive list of medicines intervention for a hospital stay or for treatment in a health care institution Are excluded: esthetic care provisions that do not meet the reimbursement criteria 24

25 4. Coverage What is the extent of the coverage? both preventive and curative care required for maintaining and repairing a person's health medical care is divided in 25 different categories, the most important of which are these: ordinary medical care (GP, specialist, ) - dental care deliveries - pharmaceutical products (pharmaceutical specialities, generic drugs, ) - hospital care - help required for revalidation etc. 25

26 4. Coverage HOW MUCH DOES THE INSURANCE PARTICIPATION AMOUNT TO? Medical care: 75 % of the conventional fees Medicines: according to the category of medicine» cat A (severe and prolonged diseases) 100%» cat B (medicines useful from a social and medical point of view) 75%» cat C, Cs, Cx (medicines with a low therapeutic value) 50% to 20% Hospitalization: fix amount per admission + fix amount per day to be paid by the people insured (cost of stay and medicines) 26

27 4. Coverage HOW MUCH DOES THE INSURANCE PARTICIPATION AMOUNT TO? (2) Social corrections system BIM maximum bill (MAF) Special Solidarity Fund Real personal contribution on average 7.07 % (2007) after being taken into account in the maximum bill 27

28 4. Coverage WHO DOES DETERMINE WHICH PROVISIONS CAN BE REIMBURSED? Legal definition of the health care package Establishment of the nomenclature of the medical provision of services and related lists by mixed technical commissions of NIHDI (health care providers, universities, insurance carriers) and confirmation by the management bodies and the minister Determination of the relative values of the provisions 28

29 4. Coverage FEES Fees for service or drug delivery Fix fees (per day, per admission) Mixed fees REIMBURSEMENT BASES Medicines and medical devices BUDGETS ACTIVITY BASED OR PER DIEM Hospitals, day centers, rest homes, rehabilitation ti centers 29

30 4. Coverage HOW TO FIX TARIFFS? Conventions (equal composition) Agreement within a national joint commission Approval by the management bodies and the minister Adhesion of a minimum amount of health care providers (60 %) If no agreement: reference tariff or government tariff 30

31 Basic characteristics ti of the system Compulsory social insurance (refund system); Close to a universal coverage; Management, consultation and agreements on fees by and with the social partners, health insurance funds and health care providers; Freedom to choose the health care provider and major therapeutic freedom; Reasonable prices but sometimes big quantities; 31

32 Basic characteristics ti of the system Pretty good score in terms of accessibility; Financial solidarity (contributions completed by state interventions); Fee of the health care provider is mainly based on the operation performed; Large selection of health care providers and structures; Focus on the vertical organization (structure with compartments) rather than the horizontal approach (integrated care). 32

33 Republic of Korea: questions Recent major health care reforms (accessibility, sustainability and quality) Future development SIS-card and European Health Insurance Card 33

34 Protection measures BELGIAN HEALTH CARE SYSTEM Major health care reforms : 2010: 1. Increasing accessibility The compulsory coverage of self-employed has been extended to minor risks Extension of the OMNIO-system to all persons under a fixed income limit More categories of out-of-pocket payment are progressively integrated in the MAB-counter Fixed payments systems (chronically ill patients, incontinence material, ) Plan for chronically ill patients t Supplements in two-person rooms forbidden 34

35 Major health care reforms : 2010: 1. Increasing accessibility Mechanisms to provide an adequate supply Reinforcement of attractiveness of the GP profession (Impulseo fund, ) the nursing profession in hospitals, nursing homes and home care (VINCA project, ) Improving elderly care Innovative projects to allow older people to remain as long as possible in their homes Converting beds in homes into nursing home beds Prevention measures National Cancer plan National Action Plan for Alcohol 35

36 Major health care reforms : 2010: 2. Assuring health care quality Assessing the performance of the health system Regular reporting on health system performance in Belgium (1 st report June 2010) Making health care providers accountable Improving prescribing behaviour Additional feedback on prescription (e.g. Prenatal care) Recommendations for pharmaceutical products Medical evaluation and inspection departement Reform (structure, mission and enforcement rules) New definitions on breach of responsibilities from health care providers + penalties and measures 36

37 Major health care reforms : 2010: 2. Assuring health care quality Strengthening primary care Expanding the preventing role of GP Promoting grouping of GP s (Impulseo II) Promoting the integration ti of health services and multidisciplinarity Patient pathways (chronic renal failure and types 2 diabetes) Therapeutic projects in mental health care National Cancer plan 37

38 Major health care reforms : 3. Maintaining financial sustainability Fund for the future of healthcare Pharmaceuticals Provisional fund for pharmaceuticals Reforms of the reference reimbursement system New system of remuneration for pharmacists Implants and medical devices New Commission Notification for each implant New reimbursement rsement procedurere 38

39 Future development Simplification of administrative procedures (OMNIO, ) Additional measures for chronically ill Increasing attractiveness of GP and nursing profession Improving organization of medical emergency Reducing medical radiation exposure Recognition standards for paramedical professions 39

40 MORE QUESTIONS? 40