A Belgian cooperation platform Thomas Rousseau NIHDI - COOPAMI. Thomas Rousseau

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1 A Belgian cooperation platform Thomas Rousseau NIHDI - COOPAMI Thomas Rousseau NIHDI COOPAMI 2

2 Contributif Social security What i m going to talk about Presentation: only on social security in the strict sense! focus on the Belgian health care insurance! Social protection Social assistance Non contributif

3 What i m not going to talk about

4 Usefull information Report of the European Observatory on Health Systems and Policies: Gerkens S, Merkur S. Belgium: Health system review. Health Systems in Transition, Websites: National Institute for Health and Disability Insurance: ww.riziv.fgov.be The B. Health Care Knowledge Centre: FPS Social Security: E mail for questions:

5 The Belgian health insurance I. Social security in Belgium II. Financing of the compulsory health insurance III. Systems of payments IV. Basic principles of the Belgian health insurance V. The management of the health insurance VI. The future? VII. Summary

6 The Belgian health insurance 1. SOCIAL SECURITY IN BELGIUM

7 Social Security in Belgium (1) Social security is a public system of social assurances. 3 systems of social security Salaried persons 79% Selfemployed persons 12% Civil servants 6% Its own reglementation Its own social protection Its own methode of financing

8 Social Security in Belgium (2) The social security contains different sectors: Salaried persons Selfemployed persons Civil servants Insurance for accidents at work X X Insurance for occupational diseases X X Unemployment X Insurance for medical care and benefits X X X Pensions X X X Family benefits X X X Annual vacation X X Bankruptcy X

9 Social Security in Belgium (3) Expenditures of social security 2010 Soins de santé 27% 24% TOTAL: EUR Pensions Health care Incapacité de travail Chômage Politique du marché du travail Pensions de vieillesse Pensions de survie Allocations familiales Autres risques couverts Source: SPF Sécurity Sociale

10 Social Security in Belgium (4) Who is collecting and managing the money for the social security? 2 collecting institutions National Social Security Office (NSSO) National Institute for the Social Security of the Self Employed (NISSE) Salaried persons and fonctionnaires Self Employed persons

11 1.Salaried persons

12 Salaried persons (1) Salaried persons National Social Security Office Sector Employee contribution (%) Employer's contribution (%) Total (%) Medical care 3,55 3,80 7,35 Indemnités 1,15 2,35 3,50 Unemployment 0,87 1,46 2,33 Pensions 7,50 8,86 16,36 Family benefits 0,00 7,00 7,00 Accidents at work 0,00 0,30 0,30 Occupational diseases 0,00 1,00 1,00 TOTAL (= global contribution) 13,07 24,77 37,84

13 Salaried persons (2) Social contributions Government subsidies Alternative financing 66% 10,3% 23,7% Why? limit government subsidies reduce employers' contributions National Social Security Office Globalisation of the financial resources and management of incoming funds NPO NIHDI Distribution of financial resources between sectors according to the real needs

14 2. Self Employed persons

15 Self Employed persons (1) The self-employed pay their quarterly social security contribution to the social insurance fund they are affiliated with. The contribution is calculated on the self-employed person's net professional labour income in the third calendar year ('reference year') preceding the year for which the contribution is due. Professional income per bracket Amount of the contribution Up to ,43 692,86 per quarter Between ,43 and ,06 22% of net professional income Between ,06 and , % of net professional income More than ,52 0

16 Self Employed persons (2) 18,08% 0,37% Financing Social Contributions Government subsidies Alternative financing 23,15% 58,40% Others

17 The Belgian health insurance 2. FINANCING OF THE COMPULSORY HEALTH INSURANCE

18 Financing of compulsory health insurance SOURCES (millions ) % Social contributions + government ,14% subsidies + alternative financing Retirement contribution ,27% Car insurance ,63% Fire insurance ,62% Tax on profit of pharmaceutical ,90% companies Complementary hospital insurance ,43% Internationale conventions ,31% Other sources ,69% Total %

19 Expenditures Social health Insurance expenditures 2012 (000 ) Reimbursement of health care services Internationales conventions Administration costs sickness funds Administration costs NIHDI Other expenditures total expenditures

20 Partial objectives 2,18% 3,28% 2,70% 2,43% 4,46% 4,67% 0,98% 0,17% 0,13% 0,06% 1,60% Doctors 29,09% Health care sectors Médecins Hôpitaux Médicaments Maisons de repos Infirmiers 9,24% Solde Dentistes Pharmaceutical products 17,70% Hospitals 21,31% Implants Kinésithérapeutes Rééducation Dialyse Bandagistes et orthopédistes Audiciens Opticiens

21 Fixation of the budget How do we fix yearly the reimbursement budget of health care?

22 Fixation of the budget Budget = The annual amount necessary for the health insurance to cover the reimbursement of health care for the Belgian population. = Global budget objective

23 Fixation of the budget Health Insurance Act: Budget T 1 + Growth norm(%) + Inflation T (%) = Budget T

24 The real growth norm Fixing the annual global budget objective is therefore not subject to a vote in parliament, but the parliament can change the growth norm Evolution ,50% ,50% ,50% ,00% ,00%

25 New initiatives and savings measures New initiatives and savings measures in health care Year initiatives savings measures net effect cumulative net effect

26 The Belgian health insurance 3. SYSTEMS OF PAYMENTS

27 Systems of payments (1) Insured / Patient Health care provider Health insurance fund

28 Systems of payments (2) Health care providers Generally organized as self employed professionals The general practitioner : works mainly in private practice The medical specialist: can work in health institutions (mostly hospitals) and/or on an ambulatory basis in private practice Therapeutic freedom for physicians A significant proportion of health care providers are paid on a fee for service basis No referral system between GPs and other specialists

29 Systems of payments (3) Health insurance fund Private non profit making organizations with a public interest mission They are grouped into 5 national associations according to their political or ideological background : 1. National Alliance of Christian Mutualities 2. National Union of Neutral Mutualities 3. National Union of Socialist Mutualities 4. National Union of Liberal Mutualities 5. National Union of the Free and Professional Mutualities Their role in the compulsory health insurance system 1. Ensure the reimbursement of health care expenses and the provision of an alternative income in case of incapacity to work. 2. Control of conformity with the legal rules (advisory physicians) 3. Provide information to their members and the health care providers The compulsory insurance package and the social contribution rates are identical for all funds

30 Systems of payments (4) Insured / Patient 2 obligations: 1. Affiliate or register with a health insurance fund 2. Paying social security contributions Freedom of choice: health care provider (+ right to a second opinion) sickness fund

31 Systems of payments (5) 1. A system of reimbursement Insured / Patient the full fee Health care provider certificate Health insurance fund Reimbursement = Official fee Co payment

32 Systems of payments (6) 2. A system of third party paying Insured / Patient Hôpital Co payment or user charge Pharmacie bill insurance allowance Health insurance fund

33 Financing of Health insurance fund 70% of the expenditures NIHDI 30% on basis of a distribution key Health insurance funds Insured / Patient (± )

34 The Belgian health insurance 4. Basic principles of the Belgian health insurance

35 Universal coverage 3 dimensions ± 80% > 99% Nomenclature codes

36 Compulsory insurance A compulsory insurance 1. All working people have to pay social security contributions and equal a minimum amount 2. All entiteld persons must affiliate with a sickness fund (NO RISK SELECTION!) +pay a small flat rate premium

37 Solidarity 1. Horizontal solidarity: between good and bad risks 2. Vertical solidarity: between rich and poor Sociale contributions are related to the income and do not depend on the health risks!!! 3. National solidarity: all the citizens ar paying as a whole Subsidies from the federal Government

38 Equity (1) Protection measures for lower socioeconomic groups A system of increased reimbursement widows, disabled persons, pensioners, orphans and some unemployed persons all persons under a fixed income limit Maximum Billing (MAB) System making sure each family does not have to spend more than a maximum amount on some health costs. Exact amount depends on the family income. Calculated yearly

39 Equity (2) Other protection measures Special Solidarity Fund Additional reimbursement for patients with a rare illness or who need a very specific treatment Fixed payments to patients who can be expected to have high medical expenditure For chronically ill patients For incontinence material For palliative treatment at home

40 The Belgian health insurance 5. The management of the health insurance

41 The management of the health insurance NIHDI National union of health insurance funds Health insurance funds Insured / Patient

42 NIHDI (1) The National Institute for Health and Disability Insurance Since 1963 A public social security institution under the responsibilities of the Minister of Social Affairs (and Public Health) Extended management autonomy Management agreement Manages and supervises the compulsory health care and benefits insurance

43 NIHDI (2) Preparation and realisation of public health policy The organization and financing of health care institutions The organization of health professions The emergency medical FPS Health Ministère NIHDI Public social security institution General organization and financial management of the compulsory health care and benefits insurance Organize reimbursement of medical costs Elaborate legislation and regulation Monitor the evolution of health care spending Inform health care providers, sickness funds and the insured, and to ensure they apply the legislation and regulation correctly Organize the negotiations between the different actors involved in compulsory health insurance

44 NIHDI (3) Departments General ManagmentCommittee CEO & Deputy CEO Internal audit Cell Communication Cell Modernisation ± 1350 staff members Cell Datamanagement Cell Expertise & COOPAMI Safety information Prevention service Health care Departement Benefits Department Medical Evaluation and Inspection Department Administrative Inspection Department General Support Departments Fund for Medical Accidents

45 Stakeholders The collective negotiation process in the health insurance (1) Government Employers NIHDI Salaried employees and self employed workers Health care providers Sickness funds

46 The object The collective negotiation process in the health insurance (2) The global orientations on health policy and global budget General reglementation The reimbursed medical services the nomenclature The remboursement tariffs and fees

47 The collective negotiation process in the health insurance (3) Negotiation bodies Minister of social affaires General management Committee for Health Care Insurance General Council Budget Control Committee Sectoral negotations Conventions and agreements commissions Preparatory negotations Technical councils Workgroups

48 The collective negotiation process in the health insurance (4) Example: The budgetary process Negotiation body Conventions and agreements commissions Health Care Department of the NIHDI Budget Control Committee Mission Determination of needs Carries out technical estimates Identification of potential economy measures Health Care Insurance Committee Suggestion of a global budget objective + its breakdown into partial objectives General Council Decision on a global budget objective + its breakdown into partial objectives Conventions and agreements commissions Negotiation of conventions and agreements

49 The Belgian health insurance 6. THE FUTURE?

50 The objectives of the Belgian health care system Maintaining financial sustainability Increasing accessibility Assuring health care quality

51 The long run challenge: accommodating increasing expenditures (1) 5 Trends in health expenditure in Belgium, ,5 4 3,5 3 2,5 2 Total health expenditure GDP 1,5 1 0,

52 The long run challenge: accommodating increasing expenditures (2) Factors driving health care spending in past decades Policy decisions to enlarge acces Demand for better quality health care linked to growing income levels Technology evolution Futur chalanges Increased health threatening lifestyles Men: 49% overweight 14% obese Women: 28% overweight 13% obese Increasing of chronic diseases Improved wellbeing and a better standard of living Growth and progress of new technologies and treatment An aging population

53 The long run challenge: accommodating increasing expenditures (3) Percentage of households that had to postpone medical care because of financial reasons, by income level 25,0% 20,0% 21,4% 23,1% 18,7% 15,0% 10,0% 8,6% 10,6% 10,6% 5,0% 0,0% < 750 euro euro euro euro > 2500 euro Total Source: KCE, 2010

54 The long run challenge: accommodating increasing expenditures (4) What to do? Low expenditures High expenditures Growth of private alernatives Further extension of the collective system Increasing cost awareness of the players Increasing the efficiency Increasing the prevention Rewarding quality Improving the information system

55 The Belgian health insurance 7. SUMMARY

56 The main features of the Belgian health care system A liberal view of medicine The patient has the freedom to choose High quality care A system of compulsory health insurance system Decision making based on negotiations

57 We welcome your questions, suggestions, comments!

58

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