Belgian Health Care System Jo DE COCK - CEO National Institute Health & Disability Insurance (NIHDI) Brussels 9 November 2011 1
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
System of third party paying Insured people/ patients Patient s contribution Health care providers Health insurance funds 3
HISTORICAL FACTS 1945: introduction of social security and compulsory health care insurance for workers 1963: basic law and establishment of NIHDI 1993-1994: changes in management and introduction of a system of financial responsibility 2001-2010: successive reforms in order to make NIHDI more accessible and sustainable 4
NIHDI: Organizational chart General Management General Management Committee Sector Management General Council --------------------------- Committee for Health Care Insurance Management Comitee Wage-earners ---------------------- Management Comitee Self-employed persons Committee Department for Administrative control General Support Departments Administration Health Care Department Department for Invalidity Benefits Department for Medical Evaluation and Control 5
1. Administrative 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
1. Administrative 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
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
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
1. Administrative organization EXECUTION MUTUALITIES reimbursement to all persons insured negotiating prices and fees (collectively) information 10
1. Administrative organization CONTROL Mutualities NIHDI Administrative control Medical evaluation and control (reality/conformity and overconsumption) Mutualities Control Body 11
2. Entitlement 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 and their dependants. The main insured members are entitled to health insurance on the basis of their current or previous profession. 12
2. Entitlement 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 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
3. Funding SOURCES OF FUNDING Social contributions (through 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
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
3. Funding Year 2010 In billions of In % Global management 23.035 82,7 VAT / Excises 2.468 8,9 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 0,1 27.864 100 16
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 825.6 0.0 2 499.0 1 098.6 331.5 15 430.1 2 252.3 1 048.8 447.6 614.2 1 380.3 525.3 102.2 6.8 31.4 17635.90 (66,3 %) 2777.60 (10,4 %) 3650.00 (13,7 %) 1553.00 (5,8 %) 977.10 (3,7 %) Total 4 754.6 19 793.1 2 045.9 26593.60 (100,0 %) 17
Some important data from 2007 with regard to Belgian health care expenses (Source : FPS Social Security and NIHDI) TOTAL HEALTH CARE EXPENSES 32.774,3 (in millions of ) GDP = 334.947,80 Mio EUR 9,8 % GDP Private Public 24.830,40 7.973,90 Reimbursements through security social Through NIHDI (excl. Soc & fisc MAF + regul 171,90) 20.564,30 18.299,40 Out of pocket 6.226,80 Insurances 1.627,20 Through Mutualities 889,30 In pharmacies 2.340,70 18
BELGIAN HEALTH CARE SYSTEM 3. Funding Expenditure Health care budget of the NIHDI 2003 15,3 billion 2004 16,3 billion 2005 17,4 billion 2006 18,5 billion 2007 19,6 billion 2008 21,4 billion 2009 23,1 billion 2010 24,2 billion 19
3. Funding Source : OECD Health Data 2009 - Version: October 2009 Total health expenditure as % of GDP, 2007 (US $) per capita / Belgium 2007 Public health expenditure as % of total health expenditure, 2007 % GDP % % BE 10,2 100 % 72,3 NL 9,8 * 107 % 74,8 FR 11 100 % 79 DE 10,4 100 % 76,9 UK 8,4 83 % 81,7 CZ 6,8 45 % 85,2 US 16 203 % 45,4 * Exclusive investment 20
Figure 1. Total health expenditure expressed as % of GDP in selected OECD countries, 1995 2006. 21
Figure 2. Total health expenditure expressed per capita (US$ PPP) in selected OECD countries, 1995 2006. 22
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
4. Coverage WHICH PROVISIONS ARE COVERED? Preventive and curative care mentioned in a nomenclature (consultations, visits, 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
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) 25
4. Coverage HOW MUCH DOES THE INSURANCE PARTICIPATION AMOUNT TO? (2) Social corrections Increased reimbursement beneficiary (IRB) - OMNIO Maximum Billing (MAF) Special Solidarity Fund Real personal contribution on average 7.07 % (2007) after being taken into account in the maximum bill 26
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 27
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 centers 28
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 29
Basic characteristics 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; 30
Basic characteristics 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). 31
Major health care reforms 2007-2010: 1. Increasing accessibility Protection measures 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 Supplements in two-person rooms forbidden 32
Major health care reforms 2007-2010: 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 33
Major health care reforms 2007-2010: 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 34
Major health care reforms 2007-2010: 2. Assuring health care quality Strengthening primary care Expanding the preventing role of GP Promoting grouping of GP s (Impulseo II) Promoting the integration of health services and multidisciplinarity Patient pathways (chronic renal failure and types 2 diabetes) Therapeutic projects in mental health care National Cancer plan 35
Major health care reforms 2007-2010: 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 procedure 36
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 37
MORE QUESTIONS? coopami@inami.fgov.be 38