the compulsory health care insurance. A kaleidoscopic view. Chris Segaert NIHDI Dept. of health care Dir. International relations

Transcription

1 The Health lhcare System in Belgium : the compulsory health care insurance. A kaleidoscopic view. Chris Segaert NIHDI Dept. of health care Dir. International relations 1

2 Summary I. Introduction II. III. IV. Organisationalstructure structure & management Health care finance & expenditure Compulsory health care insurance V. Conclusion 2

3 I. Introduction 3

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

5 TheBelgianhealthcare health systemismainlyorganised mainly on two levels : federal compulsory health hcare insurance, financing i of hospitals and heavy medical care units, registration ofpharmaceuticalsand and their price control, regional health promotion, preventive health, different aspects of elderly care, financing of hospitals, 5

6 Constitutional structure 6

7 Constitutional structure 3 Communities responsible for a series of issues associated with language and culture 7

8 Constitutional structure 3 Regions responsible for a series of issues associated with territoryin in the broadsense of the word 8

9 II. Organisational structure & management 9

10 (source : Gerkens S. Merkur S., Belgium: Health system review. Health Systems in Transition, 2010, vol. 12, No. 5) 10

11 Actors on the federal Belgian level FPS (Ministry) of Public Health, Food Chain Safety and Environment FPS (Ministry) of Social Security NIHDI Health insurance fund ( mutualités ) Health care providers Insured persons / patients 11

12 Administrative organisation Regulation FPS of Social Security FPS of Public Health, Food dchain Sft Safety and Environment legislation covering different professional qualifications (exercising the art of healing) hospital legislation and heavy medical care units (hospital financing e.g. day care, accreditation standards, ) market registration of pharmaceuticals (and medical devices) and their price control l(through h Agency) other public health issues 12

13 Administrative organisation Regulation NIHDI : management of the health hcare insurance financial management of the health care insurance administrative organisation of the health care insurance provides support during the consultation ti process 13

14 Administrative organisation Regulation NIHDI structure t Management bodies: General Council (government, employees, employers, health insurance funds) Insurance Committee (health insurance funds, healthcare providers) Insurance bodies: Conventions and agreements commissions Technical boards Scientific bodies: Scientific Board for Chronic Diseases National Board for Quality Promotion Assessment Committee for Drug Prescription 14

15 (source : Gerkens S. Merkur S., Belgium: Health system review. Health Systems in Transition, 2010, vol. 12, No. 5) 15

16 Administrative organisation Execution Health insurance funds ( mutualités ) reimbursement to all insured persons negotiating prices and fees (collectively) information private not for profit 16

17 Administrative organisation Control Health insurance funds ( mutualités ) NIHDI administrative control medical evaluation and control (reality/conformity and overconsumption) Supervising Authority of health hinsurance funds 17

18 Organisational structure & management (source : Gerkens S. Merkur S., Belgium: Health system review. Health Systems in Transition, 2010, vol. 12, No. 5) 18

19 III. Health care finance & expenditure 19

20 Health care financing Social security contributions (through NSSO) employers (3,80 % of the salary) employees (3,55 % of the salary) Government subsidies and taxes (VAT) External sources of funding, such as insurance companies pharmaceutical industry Patient contributions (Private insurance) 20

21 Health care financing 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 21

22 Health care financing Budgeting the compulsory health care insurance (source : Gerkens S. Merkur S., Belgium: Health system review. Health Systems in Transition, 2010, vol. 12, No. 5) 22

23 Health care budget of the NIHDI ,4 billion ,5 billion ,6 billion ,4 billion ,08 billion ,25 billion ,87 billion 23

24 Source : OECD Health Data Version: June 2009 Total health expenditure Public health expenditure as % as % of GDP, 2007 of total health expenditure, 2007 % GDP Per capita % (US $) BE 10, ,3 NL 98 9,8 106,7 FR 11,0 100,2 79,0 DE 10,4 99,8 76,9 UK 8,4 83,2 81,7 TR (2005) 5,7 18,7 71,4 US 16,0 202,8 45,44 24

25 Summary health care costs in the broadest sense (treatment, reimbursable and non reimbursable medicines, infrastructure expenses, ) are largely born by three main components : the community : ± 76,4 % the patients : ± 17,7 % the private insurers : ± 59% 5,9 25

26 IV. Compulsory health care insurance 26

27 Who is covered? practically the whole population - family based scheme conditions to be eligible : - compulsory membership of health insurance fund - payment of a minimum contribution - (six month waiting period) 27

28 What is the extent of the coverage? both preventive and curative care required dfor maintaining i i and repairing a person's health medical care is divided in 25 different categories, the most important of which are ordinary medical care (GP, specialist, ), dentalcare care, pharmaceuticalproducts products (pharmaceutical specialities, generic drugs, positive list), intervention for a hospital stay or for treatment in a health hcare institution, help hl required for revalidation, ld etc. excluded: esthetic ti care provisions that do not meet the reimbursement criteria 28

29 The Belgian health care insurance provides a financial i contribution tib ti to the costs, i.e. reimbursement system 29

30 How can patients obtain reimbursement? standard procedure : reimbursement a posteriori special rule : third party payer system compulsory for hospitals retail pharmacy 30

31 System of reimbursement fees doctor, dentist, physiotherapist, wheelchair,... patients affiliation reimbursement = fee PATIENT S CONTRIBUTION (out of pocket payments) health insurance funds 31

32 System of third party paying patient s contribution insured people/ patients health care providers health insurance funds 32

33 How are reimbursable benefits determined? legal definition of the health care package nomenclature of medical services (± fee schedule) list of medicines qualifying for reimbursement the health care services which are reimbursed, their amounts tsand dthe econditions o under which they eyae are reimbursed are determined by the NIHDI in consultation with the various actors involved (health care providers, universities, health insurance funds), and confirmation by the management bodies and the minister (taking into account the budgetary limits) 33

34 What is the insurance contribution? medical care: 75 % of the conventional fees pharmaceuticals: according to the category of the pharmaceutical cat A (severe and prolonged diseases) 100% cat B (medicines useful from a social iland medical point of view) 75% cat C, Cs, Cx (medicines with a low therapeutic value) 50% to 20% hospitalisation: fixed amount per admission + fixed amount per diem to be paid by the insured person (cost of stay and pharmaceuticals) 34

35 What is the insurance contribution? Social corrections system BIM / OMNIO system of maximum billing (MAF) fixed payment systems (patients suffering from a chronic disease, incontinence material,...) Special Solidarity Fund Actual personal contribution on average 7,07 % (2007) after application of the MAF 35

36 IV. Conclusion 36

37 Key characteristics of Belgian health care system Compulsory social insurance (refund system) Near universal coverage Management, consultation and agreements on fees by and with the social partners, health insurance funds and healthcare providers Freedom to choose the health care provider and major therapeutic freedom Reasonable prices but sometimes big quantities 37

38 Key characteristics of Belgian health care system Pretty good score in terms of accessibility Social solidarity principle (contributions completed by government contributions) Fee of the health care provider is mainly based on the medical service provided d Large offer of health care providers / services Focus on the vertical organization (structure with compartments) rather than the horizontal approach (integrated care) 38

39 Thank you for your attention. More information : coopami@riziv.fgov.be 39