NIHDI INAMI RIZIV- LIKIV NOMENCLATURE AND ALTERNATIVE WAYS OF FINANCING MEDICAL ACTS

Transcription

1 NIHDI INAMI RIZIV- LIKIV NOMENCLATURE AND ALTERNATIVE WAYS OF FINANCING MEDICAL ACTS Dr Antonine Wyffels 11/03/2014

2 Introduction National Institute for Health and Disability Insurance: organizes the reimbursement of the medical costs in order to make high quality health care accessible to as many people as possible organizes the negotiation between the different partners of the health insurance makes sure the activities of the health care providers and health insurance funds are properly financed

3 Nomenclature: definition Part of the (common) services that are covered by compulsory health insurance are described in the nationally established fee schedule = NOMENCLATURE It is an index of reimbursable (para-)medical health care acts (intellectual, material, technical or mixed) Extremely detailed list of more than 8000 health care services: consultations visits physiotherapy sessions nursing care protheses and implants

4 Nomenclature: legal framework The legal framework of the nom is the Royal Decree of 14 september Published as an annex of the RD Updated by new RD at each modification Published in the Moniteur Belge as amendments to that annex. Sickness funds are legally bound to reimburse any claim from their insured members for care delivered by any recognized health care provider at the agreed fee levels!

5 Nomenclature: contents? (1) Provides the following information (1/2): Qualification of the health care provider An identification number or code for each service: Composed of 6 numbers. Mentioned on the medical certificate In most cases, there are two codes: one for outpatients and one for inpatients. A description or definition of the service Application rules: explaining the conditions of reimbursement of one or more services

6 Nomenclature: contents? (2) Provides the following information (2/2): A letter-key: gathers a certain number of services: N for consultation, visit, technical service L for dentists Z for opticians the value of the letter-key is negotiated yearly or biennially between representatives of the sickness funds and of the health care professionals A coefficient: indicates the relative value of the individual service Value of letter-key x coefficient = maximum amount of the fee

7 Nomenclature: example An appendicectomy is the surgical removal of the vermiform appendix. Appendectomy may be performed laparoscopically ( / N200) or as an open operation ( / N200) Article 14 of the nomenclature - Surgery

8 Nomenclature: creation? (1) Technical councils Conventions and agreementscommissions Budget Control Committee Health Care Insurance Committee Minister of Social Affairs

9 Nomenclature: creation? (2) Technical Medical Council Is in charge of the technical contents of the nomenclature Members: Two thirds of experts are from the Belgian universities and the professional organizations who are representating the medical community A third are doctors of the national unions of sickness funds Make proposals or formulate recommendations to adapt the services of the nomenclature or to add new once

10 Nomenclature : creation (3) AGREEMENT COMMISSION : Is in charge of the financial aspects Members : professional organizations and sickness funds

11 How is decided the value of an act? By refering to a standard act in the same field By calculating the necessary ressources By taking into account th available budget.. By a lot of discussions!!

12 Strong points of the nomenclature Repository of the reimbursed services Avoid confusion/disagreement Simplified invoicing Epidemiologic follow-up Follow-up of the activity: Who prescribes/carries out? How much? Where? Follow-up of the expenditures (permanent audit) Possible to update (but takes time) Public document Respect of diagnostic and therapeutic freedom Result of negotiation tariff safety

13 Weak points of the nomenclature Long introduction period for each modification or innovation Progressive complexification Difficulty in limiting the abuses without creating problems of accessibility to the care. Not adapted for special or rare services Not well known by the health care providers by increasing complexity Raising difficulty to coordinate different reimbursement models

14 How to cope with the weak points? Our concern : how to introduce innovation, how to concentrate excellence and experience in health care? One possible answer : contracts with specific centers Other models of financing

15 Contracts : quick and simple procedure BUT time-consuming Discussion is held in working groups, specific councils, Approval by Health Care Insurance Committee Implementation by contracting with the centers Follow-up and evaluation Negative : needs for human ressources ++ in order to organize meetings for follow-up and evaluation, resulting in possible adjustments of the contract stipulations.

16 Example of contracting Reimbursment of hepatic dialysis : A number of centers, with a team of specific physicians A list of (contra)indications A specific fee/lump sum A tight follow-up : each reimbursment has to be approved individually files has to be introduced within a fixed deadline Evaluation by annual reports

17 EVOLUTIONS Fee for service lump sums (multidisciplinary care,..). Pro and contra Increasing deductions are made from the doctors fees by the hospitals tension! Increasing of the individual payment by the patients by an increasing number of physicians not subscribing the convention with the sickness funds.

18 More info? Electronic consultation of the nomenclature NomenSoft : nomenclature database Code-numbers Description Tariffs (fees / prices / reimbursement rates) Website of the NIHDI :

19