Maintenance and Improvement of quality health care
The Belgian
Health Care System Revisited
Dr. M.
MOENS
Secretary-general
VBS-GBS
Brussels,
September 27, 2003
1.
INTRODUCTION
I am grateful to
Prof. Luc BAERT for having invited me on the occasion of this symposium to
formulate a number of considerations concerning "the maintenance and
improvement of quality health care in Belgium" from the viewpoint of a
professional association of medical practitioners.
As elsewhere in
the industrialized world, the Belgian health care system is under to pressure.
The cornerstones, which Prof DILLEMANS has just described, are they in need of
replacement or, will the addition of contemporary accents be sufficient ?
Belgian
physicians have always had misgivings about the interference of the Government
in their practice. For almost 40 years,
or more precisely since 25.06.1964, a system of conventions has existed between
the physicians and the sickness funds for the admission of certain medical
treatments into the Government financed health care package and on the fees for
the provision of health care services .
Until 1993,
physicians could, in mutual agreement with the sickness funds, proceed quasi
autonomously. Under Minister Philippe
MOUREAUX (Socialist party) however, this system was changed by the law of
15.02.1993. This law considerably reduced the power of both pressure
groups. Each convention concluded
between the physicians and the sickness funds now needs to be in accordance with
the governmental budget and will then need approval of the minister in charge.
Consultations
between the Government and the time-honoured partners of the system, sickness
funds and care providers (in casu the physicians) are regarded as highly
important. During the ministry of 1999-2003, with Frank VANDENBROUCKE as
minister of Social affairs, now minister of Labour and Pensions, consultations
seldom led to results that were supported by the concerned professional groups
or institutions.
In spite of
considerable investment in the health care system, almost all professional
groups felt passed over by the Government: the physiotherapists, the
pharmacists, the physicians, the hospital administrators, the pharmaceutical
industry, …
In short, any
attempt to express some entrepreneurship in a private practice or within an
institution would stay without a result under the preceding government. A great majority of health care providers
were left unhappy and frustrated. What is going wrong? Is there a way out of
this situation?
2.
PEOPLE AND MEANS
In Belgium, there
are about 285.000 people engaged in the health care sector. On the one hand, +/- 227.000 are engaged in
hospitals and other health care institutions, in practices of health care
providers, in the pharmaceutical industry and business or in the sickness
funds.
On the other
hand, there are about 58.000 independent practitioners active as physicians,
dentists, nurses, physiotherapists, … (cf table 1).
Occupation in the
health care sector (year 1999)
|
Employees in
|
146.275 30.716 25.499 13.458 11.044 |
|
Subtotal |
226.992 |
|
Independents
|
23.846 22.628 6.817 4.514 |
|
Subtotal |
57.805 |
|
Total health care employment
|
284.797 6,5 |
Table 1
Source
: BIGE compendium health statistics
2001.
From those +/- 285.000 active in the health sector
there are, for the year 2002, roughly 169.000 providers who are registered at
the Rijksinstituut voor Ziekte- en Invaliditeitsverzekering (RIZIV) (National
Sickness and Invalidity Insurance Institute, NSIII) (cf. table 2), from which
40.763 for the year 2002 are physicians.
|
|
1994 |
1998 |
2002 |
|
Nurses and
midwives Physicians Physiotherapists Paramedics Pharmacists Dentists Opticians |
50.965 35.081 22.438 14.865 9.824 7.727 2.992 |
56.708 38.109 25.009 15.282 10.656 8.240 3.200 |
63.040 40.763 27.475 14.385 11.775 8.553 3.333 |
|
Total |
143.892 |
157.204 |
169.324 |
Table 2
Source
: NSIII annual report 1998 and 2002
There is in
Belgium a very high density of physicians: for 10,3 million inhabitants there
are 46.268 physicians or one physician per 223 inhabitants. Since 1980 the
number of physicians increased on average by more than 1000 per year (cf. table
3).
Evolution in the
number of physicians in Belgium
|
|
General
Practitioners |
Specialists |
Specialists
in training |
All
doctors |
|
1950 1960 1970 1980 1984 1988 1992 1996 2000 2001 2002 |
10.968 12.985 14.371 14.897 15.378 19.443 19.444 18.367 |
9.617 11.034 12.969 14.691 16.364 19.166 20.045 23.978 |
2.084 3.077 2.972 3.579 3.460 3.427 3.489 3.923 |
8.685 11.730 14.887 22.669 27.096 30.312 33.167 35.202 42.036 42.978 46.268 |
Table 3
Source
: Ministry of Social Affairs, Public Health and Environment.
In particular the
number of specialists continues to increase steadily while, since 2000, the
number of general practitioners has come at a standstill and even drops in 2002
(cf. table 4).
Evolution of the
number of medical doctors in Belgium since 1980 (1980 = 100)
|
|
General
Practitioners |
Specialists |
Specialists
in training |
All
doctors |
|
1980 1984 1988 1992 1996 2000 2001 2002 |
100 118 131 136 140 177 177 167 |
100 115 135 153 170 199 208 249 |
100 148 143 172 166 164 167 188 |
100 120 134 146 155 185 190 204 |
Table 4
Source
: Ministry of Social Affairs, Public Health and Environment.
Not all physicians have a practice. Yet, the number of
practicing Belgian physicians is important in comparison with the other
European countries: 40.299, or one active physician per 256 inhabitants, of
which 14.541 general practitioners (1 per 709 inhabitants) and 25.758
specialists (1 per 400 inhabitants) (cf. tables 5 and 6).
Number of
physicians, per category, with and without a clinical practice (31.12.2002)
|
Category |
With practice |
Without
practice |
Total |
|
General
practitioners Generalists in
training |
13.718 823 |
3.825 1 |
17.543 824 |
|
Subtotal |
14.541 |
3.826 |
18.367 |
|
Specialists Specialists in
training |
21.897 3.861 |
2.081 62 |
23.978 3.923 |
|
Subtotal |
25.758 |
2.143 |
27.901 |
|
Total |
40.299 |
5.969 |
46.268 |
Table 5
Source
: Ministry of Social Affairs, Public Health and Environment.
(formulated in terms as one per number of inhabitants)
|
General
practitioner Specialist All doctors |
709 400 256 |
Table 6
Source
: Ministry of Social Affairs, Public Health and Environment.
From a budgetary
perspective, Belgium has spent more in the course of 2000 than the average
figure for the OECD and the European Union : 8,7% of the Gross Domestic Product
(GDP) against 8% for the OECD- and the EU-average. For 1990, Belgium's
expenditure was only just in balance with the European average, namely 7,4% of
the Gross Domestic Product (cf. table 7). During the past decennium Belgium has
thus seen a very significant increase in health care expenditure.
Growth of
expenditure on health (1990-2000)
|
|
Health spending
% GDP |
|
|
|
1990 |
2000 |
|
Belgium Germany Poland Ireland Finland UK The Netherlands OECD EU |
7,4 8,7 5,3 6,6 7,9 6,0 8,0 7,2 7,4 |
8,7 10,6 6,2 6,7 6,6 7,3 8,1 8,0 8,0 |
Table 7
Source : J. DE COCK;
NSIII; INSEAD symposium, Brussels, 23.05.2003
Amongst the
NSIII-expenses on health care, the share of doctor’s fees is considerable: 30,3
% in 2002. In terms of percentage we notice a decreasing trend : 32,6 % in 1997
and 42 % in 1970 (cf. table 8). New health care professions and new sectors
have claimed their place and their share of the budget.
Share in the
NSIII-expenditure in terms of percentage, per different categories of acts
and/or care providers
|
|
1997 |
2002 |
|
Physicians * Hospitalisation Pharmaceuticals Other care
providers ** The remaining |
32,6 25,7 18,3 11,6 11,8 |
30,3 24,2 19,3 11,4 14,8 |
|
Total |
100,0 |
100,0 |
Table 8
Source
: NSIII annual report 2000 and 2002
* In
1970 the physicians' share was 42%
** Share
of fee for service remuneration for dentists, nurses, physiotherapists and
paramedics
Despite the
rapidly growing number of physicians, their fees have seen the slowest increase
amongst all the sectors involved in health care. While during the period
1992-2002 the average yearly growth for the whole sector was 4,8%, it was only
2,5 % for doctors fees. The average yearly inflation over this period amounts
to 1,85% (cf. table 9). In the period 1992-1997 we notice a negative growth for
the doctors fees as the average index increase was 2,0 % against an average budget
growth of only 0,8 %.
|
|
1992-1997 |
1997-2002 |
1992-2002 |
|
Physicians Pharmaceuticals Hospitals Others Total |
0,8 5,7 4,5 6,7 3,8 |
4,3 7,0 4,6 8,4 5,9 |
2,5 6,4 4,5 7,6 4,8 |
Table 9
Source : J. DE COCK;
NSIII; INSEAD-symposium, Brussels, 23.05.2003
*
Inflation not taken into account
On
basis of 1988 the 12.1992 index was: 113,46,
12.1997 : 125,21, 12.2002 : 136,30.
Average
yearly inflation : 1992-1997 : 2,0 %
1997-2002 : 1,7 %
1992-2002 : 1,85 %
Over a longer
period - 1986 to 2002 – the increase in doctors fees also shows a very modest
figure, namely a yearly average of + 3,63 % (cf. table 10). The average yearly
increase in administrative costs for sickness funds is, in comparison, even a
little lower, namely 3,12 %. The average yearly inflation during the same
period was 2,67 %. It is striking that the administrative costs of the sickness funds have always shown a moderate
positive growth while the expenses for doctors fees show ups and downs due to
recurrent austerity measures.
Increase in
administrative costs of the sickness funds versus expenditure on doctors fees *
(amounts in
million euro)
|
|
Administrative
costs sickness funds |
Doctors fees |
||
|
|
Amount (1) |
Yearly increase (%) |
Amount (2) |
Yearly Increase (%) |
|
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 |
445,628 460,958 460,958 475,956 494,002 511,900 528,782 554,513 571,023 585,574 602,480 624,593 639,664 647,572 670,279 696,878 744,672 |
+ 1,17 + 0,00 + 3,25 +3,79 + 3,62 + 3,30 + 4,86 + 2,98 + 2,55 + 2,89 + 3,67 + 2,42 + 1,24 + 3,51 + 3,97 + 6,86 |
2.426,7 2.644,4 2.626,0 2.800,2 2.944,6 3.194,1 3.379,0 3.298,3 3.235,5 3.362,2 3.685,1 3.500,8 3.722,0 3.923,4 4.128,8 4.344,0 4.291,5 |
+ 8,97 - 0,69 + 6,63 + 5,15 + 8,48 + 5,79 - 2,39 - 1,90 + 3,92 + 9,60 - 5,00 + 6,32 + 5,41 + 5,24 + 5,21 - 1,21 |
|
average yearly
increase 1986-2002 |
|
+ 3,12 |
|
+ 3,63 |
|
2003 |
779,675 |
+ 4,70 |
4.747,0 ** |
+ 10,6 * |
Table 10
Source
: (1) Belgisch Staatsblad (Law gazette)
(2) NSIII
* Inflation not taking
into account
** Budget objective for
2003
With
index basis 1981, the index figure as per 12.1986 is : 131,88 and as per
12.2002 : 184,39. The average yearly inflation 1986-2002 is thus 2,67 %.
Table 11 shows in
absolute figures the different growth rhythms per sector. Only the costs for
doctors fees and hospitalisation increased during the period 1997-2002 with an
average situated in the region of a 4,5 % growth - not taking into account
inflation - which is the objective of the Government for the ministry
2003-2007. The other care providers and the expenses for pharmaceuticals show a
more significant fast growth.
The group
“remaining” increases twice as fast (10,8 %) as the approved budgetary growth
standard.
Comparison
expenditures 1997 – 2002 per different categories of acts
and/or care providers
|
|
1997 |
2002 |
Average yearly increase % |
|
|
|
in million € |
in million € |
1997 = 100 |
|||
|
Physicians Hospitalisation Pharmaceuticals Other care providers* Remaining |
3.477,473 2.743,153 1.945,473 1.233,808 1.255,786 |
4.291,476 3.429,255 2.724,349 1.616,824 2.095,057 |
123,4 125,0 140,0 131,0 166,8 |
4,3 4,6 7,0 5,6 10,8 |
|
|
Total |
10.655,693 |
14.156,961 |
132,9 |
5,9 |
|
Table 11
Source : NSIII annual report 2000 and 2002
* Fee for service remuneration for dentists, nurses,
physiotherapists and paramedics
When we look at
these fast growing care sectors we notice particularly elderly care and
revalidation, with a yearly average growth of 11,7 and 10,7 % respectively (cf.
table 12).
Comparison
between expenditures for 1997-2002 of some "strong growers" from the
category “remaining” mentioned in table 11.
|
|
1997 |
2002 |
Average yearly growth |
|
|
|
In million € |
In million € |
1997 = 100 |
|
|
Elderly care Revalidation |
640,767 181,721 |
1.113,344 302,073 |
173,8 166,2 |
11,7 10,7 |
Table 12
Source
: NSIII annual report 2000 and 2002
New needs in
health care are now also financed.
Expenditure for these "newcomers" has increased fast,
such as for the appropriate assistance in palliative care. A first prudent reimbursement of this
specific care for palliative patients responded to a modest budget of € 4,34
million in 1999. The budget objective
for 2003 already provides for € 19,96 million, which is a 4,6 times increase,
(cf. table 13), but the concerned area is aware that the needs are far more
considerable.
|
|
Million € |
1999
= 100 |
|
1998 1999 2000 2001 2002 2003 |
0,00 4,34 9,08 11,45 13,57 19,96* |
0 100 209 264 313 460 |
Table 13
Source : NSIII annual report 2002
*
NSIII budget objective
The NSIII annual report 2002 (page 189) estimates that
three quarters of the total expenses of the NSIII relate to about 10 % of the
population and that half of its total expenses are apportioned to
4 % of the population.
Let us take a closer look at the estimate regarding
this neediest group, which represents 4% of the population, in light of the
budget objectives for 2003 (cf. table 14).
Repartition of
the budget objective 2003 per different categories of medical care and/or care
providers
|
|
Million € |
% |
|
Physicians Hospitalisation Pharmaceuticals Other care
providers * Remaining |
4.746,977 3.626,082 2.696,693 2.054,624 2.217,446 |
30,9 23,6 17,6 13,4 14,5 |
|
Total |
15.341,822 |
100,0 |
Table 14
Source : NSIII annual report 2002
* Fee for service remuneration for dentists, nurses,
physiotherapists and paramedics
In line with the
above estimates, approximately 410.000 Belgians need € 7.670,911 million from
the NSIII-budget or, each patient from this group consumes approximately €
18.710.
On top of these
expenses come the costs that the patient has to pay for himself, in other words
the co-payment which represented in 2001 a total amount of € 1.363,148 million,
the non-reimbursable pharmaceuticals and, eventually, the fees which exceed the
official fees, the so-called
supplements.
Since 1995, a
part of the co-payment has been reimbursed to the minimum wage earners via a
system of social and tax exemptions.
From 2002 on, this rather complicated system has been replaced by the
maximum invoice. Once the patient's
expenses for co-payments have reached a certain maximum amount, his sickness
fund will pay the total sum of the fee to the practitioner. This maximum amount of co-payment which the
patient has to pay from his own pocket is in proportion to his income.
3. WHICH CHOICES TO MAKE IN HEALTH CARE?
The figures above
underline the importance of being careful when making choices regarding health
care. There is on the one hand, the
weakest medico-social group to take care of in an adequate way by means of easy
access to all forms of care and, on the other hand, one has to make sure that
the system of the maximum invoice does not lead to a withdrawal from solidarity
by the group with a more comfortable income.
3.1.
Co-payment and “third payer regulation”
Except for a very
small group of destitute patients, collection of co-payments must be
compulsory.
The previous
government opened the gate for an easy switch-over to the “third payer
regulation” and made it accessible for a large group of the population.
A return to
greater selectivity in the application of the “third payer regulation” is, in
our opinion, necessary. Moreover, it is
recommendable to observe the effects of the “third payer regulation” on the
sort of care that is provided. Also it is advisable to study if any
modification occurred in the expenses made by those categories of patients
which, as a consequence of the broader application of the “third party
regulation”, can systematically benefit from this pseudo-free system.
3.2.
Medical care provided by the general practitioner
We are and remain
convinced that the general practitioner is and has to remain the primary
contact person for the patient who is in need of medical assistance.
Nevertheless, the patient should be under no obligation to do so. Research
shows that 80 to 90 % of the Belgians have their own general practitioner and
that they hold him or her in great esteem.
Nevertheless,
fewer physicians appear to be choosing the profession of general practitioner
(cf. tables 2 and 3). There are multiple reasons. Are they scared by the
demanding character of the patients? Do their tutors provide them with
unrealistic perspectives of a nine-to-five o'clock job, so that they give up
after a couple of years? Are the fees too low so that the general practitioner
can not provide for sufficient staff and infrastructure in his practice? Are
the general practitioners getting burned out because of the continuous
allegations in the media that their prescriptions for pharmaceuticals are wrong
because of the heavy pressure upon them from the pharmaceutical industry, that
they prescribe too much clinical biology and radiology, too much physiotherapy
and nursing care?
Each of these
questions can be answered positively to a greater or lesser degree. Some academics’ take the view that a brighter
future for general practitioners can only be achieved by scaling up practices,
with infrastructure supported by the government, by compulsory inscription of
each patient in a specific practice, and through a lump sum remuneration
system, preferably with some target-payment.
Examples from
abroad prove that such systems certainly function no better than the Belgian
fee for service system. The general practitioner and his practice would thus be
subject to the budgetary whims of the Governments in charge. Chronic
under-financing of future staff and infrastructure, as in hospitals today, is
likely to be the result.
The cost estimate for
applying a system of Government-subsidised
group practices on a general level, amounts to
between € 400 and € 700 million. Its realization however, offers the Belgian
patient no guarantee of a better general medical care, while the hazards of
waiting lists and rationing are almost certain to become a reality.
The individual
physician who does not want to join one or another governmental structure,
risks to be discriminated. In the
so-called "Medical Houses", where a lump sum per enlisted patient is
paid to the general practitioner (and to the nurse, and sometimes the
physiotherapist), this fixed sum has been set by the NSIII at a level that is
30% higher than the average cost of a patient who is being treated in the
classic system. Moreover, these
"Medical Houses" receive very often, in addition to the NSIII-budget
further financial support from the municipality, the province, the district.
It is not our
intention to make tabula rasa of the general practice household. On the contrary, we want more of the current
system, but better. A twenty-first
century version of general practice medicine needs a considerable upgrading of
the fee for service remuneration in order to make it financially possible for
the general practitioner to run his practice on his own or in group. We plead for collaboration between general
practitioners based on their free choice, in combination with the patient’s
free choice of practitioner.
Cooperation
between general practitioners and specialists can be improved by a system of
briefing and debriefing between both groups. In the future it should be
possible that the content of the global medical file, which the general
practitioner keeps for his patient, can be electronically consulted by the
specialist and the specialist's file by the general practitioner.
Where possible,
guidelines should be formulated that do not necessarily impose sanctions. The purpose is to limit the variations in the
levels of prescriptions of pharmaceuticals, in particular of antibiotics,
clinical biology, radiology and other medical-technical services.
As an
illustration, table 15 shows the geographical differences in average amounts of
prescriptions for clinical biology per recognized general practitioner for the
year 2001. The Belgian general practitioner prescribed an average amount of €
16.273. Between the lowest amount in the
Brussels metropolitan area (€ 10.897), and the highest, in West-Vlaanderen (€
21.044), exists a factor 1,92.
|
|
EURO |
INDEX ** |
|
Brussels Metropolitan Brabant Wallon Liège Luxembourg Vlaams-Brabant |
10.897 14.204 15.453 15.739 16.044 |
67 87 95 97 99 |
|
BELGIUM |
16.273 |
100 |
|
Antwerp Hainaut Oost-Vlaanderen Namur Limburg West-Vlaanderen |
16.361 16.724 17.326 17.667 17.706 21.044 |
101 103 106 109 109 129 |
Table 15
Source
: RIZIV, note C.G.V. nr. 2003/251 dd. 28.08.2003.
* Recognized general practitioners
003 – 004 and 007 - 008
** Each average per province stands
against that of the country.
Table 16 shows
the average amount prescribed for clinical biology per general practitioner in
2001. During the year 2001, the average
Belgian was prescribed clinical biology for a total of € 22,26 by his general
practitioner. Except for the province of Namur (€ 31,22 per inhabitant), the
geographical differences are relatively limited : between € 18,98 and € 25,49.
Average of prescribed amounts for clinical biology per
inhabitant and per province by recognized general practitioners* during 2001
|
|
EURO |
INDEX |
|
Antwerp Brussels
Metropolitan Limburg Vlaams-Brabant Oost-Vlaanderen |
18,98 19,86 19,89 21,36 21,45 |
85 89 89 96 96 |
|
BELGIUM |
22,26 |
100 |
|
Hainaut Luxembourg West-Vlaanderen Brabant Wallon Liège Namur |
22,91 23,35 24,35 24,68 25,49 31,22 |
103 105 109 111 115 140 |
Table 16
Source
: RIZIV, note C.G.V. nr. 2003/251 dd. 28.08.2003.
*
General practitioners with or without acquired rights, general practitioners in
professional training and recognized general practitioners
Table 17 shows
the geographical differences of the average prescribed amounts for radiology
per accredited general practitioner during the year 2001. During 2001 the Belgian general practitioner
prescribed an average amount of 10.890 € for radiology. The factor between the lowest figure,
Brussels Metropolitan (€ 10.897), and the highest, Hainaut, is 1,73.
Average of prescribed amounts for radiology per recognized general practitioner* during 2001
|
|
EURO |
INDEX |
|
Brussels Metropolitan West-Vlaanderen Vlaams-Brabant Brabant Wallon Oost-Vlaanderen Antwerp |
8.273 8.993 9.212 10.409 10.466 10.805 |
76 83 85 96 96 99 |
|
BELGIUM |
10.890 |
100 |
|
Liège Limburg Namur Luxembourg Hainaut |
11.810 11.863 12.340 12.376 14.336 |
108 109 113 114 132 |
Table 17
Source
: RIZIV, note C.G.V. nr. 2003/250 dd. 28.08.2003.
* Recognized general practitioners 003 – 004 en 007 -
008.
Table 18 shows the
average amounts prescribed by all general practitioners for radiology during
2001. An average of € 15,60 per Belgian with a minimum of € 10,83 for
West-Vlaanderen to a maximum of € 22,62 for Namur, or a factor 2,1. Presented
as below, the figures show that all the Flemish averages are below the national
average, and that all the averages for the French speaking part of Belgium are
above the national average.
Average of prescribed amounts for radiology per
inhabitant and per province by recognized general practitioners* during 2001
|
|
EURO |
INDEX |
|
West-Vlaanderen
Vlaams-Brabant Antwerp Oost-Vlaanderen Limburg |
10,83 12,66 13,02 13,16 13,56 |
69 81 83 84 87 |
|
BELGIUM |
15,60 |
100 |
|
Brussels Metropolitan Luxembourg Brabant Wallon Hainaut Liège Namur |
16,95 18,77 19,00 20,00 21,01 22,62 |
109 120 122 128 135 145 |
Table 18
Source
: RIZIV, note C.G.V. nr. 2003/250 dd. 28.08.2003.
*
General practitioners with or without acquired rights, general practitioners in
professional training and recognized general practitioners
The best way to
discuss and adapt differences in prescription behaviour is among professionals,
via "peer-review". Within the
accreditation system - set up by the National Sickness and Invalidity Insurance
Institute (NSIII) in 1992, in which any physician may participate on a
voluntary basis - local quality evaluation groups with this aim have been
organized.
Voluntary
participation in that accreditation system avails a relatively modest increase
of medical fees.
3.3.
Specialized medicine
3.3.1.
Extramural specialists
In Belgium over
7.000 medical specialists are practising outside hospitals. A number of them are occupied in primary
health care, in the same way as the general practitioner.
They provide
easily accessible specialised health care and are, in a literal and figurative
sense, close to the patient and his general practitioner. They often provide
treatment which is cheaper for the Government than its equivalent in a hospital
structure.
Their position
however has become very difficult. They
tend to be overlooked by the legislator and are considered as competitors by
both the general practitioners and the hospitals.
In a similar way as the general practitioners, they
have to take into account the limits of extramural care. The general practitioner has to refer a
patient to a specialist in time. The
extramural specialist has to refer his patient in time to a more specialised
colleague in his area when the risks are too great or when hospital
infrastructure is necessary for strictly medical reasons.
Hospital managers
are very sceptic about such an approach. But they should not be. From an
economic point of view, it is not sensible to supply relatively commonplace
diagnostic and therapeutic activities within a structure intended for very
specialised types of treatment. The lump
sum system for hospital administrators applicable for a whole range of services
in the one-day-hospital, does not always encourage the physicians, nor the
hospital staff, to use the most appropriate means.
3.3.2.
Intramural specialists
Hospitals are bowed down with costs due to
overregulation imposed by the Authority.
The introduction of care programs and all kinds of registration
constraints on federal, community, and/or district level always requires
considerable demands on staff and infrastructure, both of which receive little
or no funding by the Authority. Its
usefulness is often questioned.
The medical
specialists who are working as independent professionals in the hospitals have
to pay the bill, although they have no or little participation in the hospital
management. Both administrators and physicians must be able to develop more
entrepreneurship in their hospitals and this on a parity basis. The role of the Government must be confined
to the creation of a general framework.
There should be more cooperation and mutual assignments between
hospitals instead of fusions creating mastodons with more than 600 beds. In
such large institutions logistical expenses, necessary to keep the whole "business"
running, increase exponentially with the number of beds. This absorbs resources
and staff which would be of better use in patient care.
From 2003 on a
system of reference amounts has been introduced in the hospitals for the so
called 28 standard pathologies. A look
at the figures for 1997 and 2000 shows that considerable variation is possible
in the use of radiology, laboratory diagnostics and other medico-technical acts
for a same basis pathology. The law of 22.08.2002 states that the hospital will
have to repay the amounts exceeding a fixed maximum which is purely based on
statistics.
Physicians who
prescribe and those who execute the prescriptions prefer guidelines and
diagnostic rules instead of a pure statistical approach. Here too, peer review is essential, inside as
well as outside the hospital, both nationally as internationally.
3.4.
Sickness funds and insurance companies
Besides the
legally compulsory sickness and invalidity insurance, there are complementary
private insurance companies and complementary insurance organized by seven
legally authorized health care insurers
– the sickness funds – which are
in the ascendant.
For example, in
addition to the compulsory health care insurance system, employers offer
hospitalisation insurance to their employees.
Both the sickness funds and the private insurers offer their members,
respectively clients, insurance for the reimbursement of alternative medicine
and other advantages which are not related to basic medical needs.
It is obvious
that no Western society is able or prepared to bear the costs of any type of
care for any inhabitant. Non adequate use of the community finances is
unacceptable, both in the health care sector, as in any other sector of the
society. In their broad working field,
physicians are willing to contribute to this on a well-founded medical basis
and amongst peers.
It will then be
up to the Government to take political decisions about the kinds of care that
will, will not or will no longer be reimbursed. A two tier medical system is
already a fact. We do not encourage this situation, but it is better to make
well-considered choices and to offer a more limited range of reimbursable
health care services so that health care quality can be guaranteed through
adequate staff and infrastructure, instead of constantly offering - without
having the means - anything to anybody. Such an attitude would result in a loss
of quality and cause frustration amongst the health care providers.
During the
Parliamentary debate that should accompany these choices, patients, physicians
and other care providers, as well as insurers should be involved.
The insurability
of healthcare that is considered less essential and is therefore not included
in the basic reimbursable package, must be guaranteed by private insurers.
Since the law on patient rights offers no guarantee that all health care will
be (partly) paid by the Government, the legal possibility must be foreseen for
complementary private care insurance to cover the health care services that the
Government can not or does not want to reimburse, while respecting a number of
solidarity principles.
Finally, the
adjustment of the law on professional responsibility, should be of primary
concern, as the present uncertain situation leads to a defensive and expensive
medicine.
3.5. Training
During medical
school and during the general practitioners' or specialists' training, the
academic world pays little attention to raising an awareness of the costs
involved with medical conduct. A
critical approach resulting in evidence based medicine is not always
accepted. A medical student or assistant
will be fully blamed when he forgets to prescribe one test in the process of
making his diagnosis, but will be easily excused for prescribing ten too many
from which no useful information can be expected.
It seems evident,
but daily practice proves differently: firstly a thorough clinical examination
is necessary, which can be followed by a complementary examination if
necessary. This first rule also counts for specialised medicine. Research has proved that the prescription of
medico-technical examinations is related to the medical school where the
physician received his or her training.
Some schools are more clinically oriented others more technically. These differences in training need an urgent analysis
and must be eliminated.
4.
CONCLUSION
Belgium has a health care system with particular
characteristics, most likely caused by its geographical situation on the border
between North- and South-Europe and resulting in a mixed medical culture.
Patients are in general highly satisfied and health
care is accessible and affordable.
On the other hand, the level of job satisfaction among
care providers is decreasing. Proposals
for drastic reform in the organisation of health care, such as general practitioners'
group practices subsidised by the State and salaried employment for all
hospital physicians, are not supported by many physicians.
Moreover, these changes would be responsible for an
exponential increase in expenditure on health care and the whole lot of red
tape.
We have enumerated a number of specific areas where
there is room for improvement.
Any remedy will need to be the result of a dialogue
between all the parties involved patients included.
Patients, in general, have great confidence in general
practitioners, medical specialists and health care suppliers. The Government and the profit sector, on the
other hand, have an ingrained distrust of the care providers in general and
physicians in particular.
In order to maintain the confidence of our patients,
we ask consideration for our professional autonomy and less condescension from
the many authorities in charge of this little country. If the proposed interventions are not
sufficient to restore the budgetary balance, the law will have to accept a
second insurance level on a private basis.
Thank you for your attention.