The role of the Socialist Mutual Health fund in the management of the Belgian healthcare system

Transcription

1 The role of the Socialist Mutual Health fund in the management of the Belgian healthcare system Basic principles and key features Department of European and International Affairs Alain Coheur

2 Presentation overview I. Introduction Towards a mutual learning perspective II. III. The Belgian healthcare system (healthcare insurance) in a nutshell The Mutual Health Funds, an essential role in the Belgian health insurance Today What is a Mutual Health Fund? Three fundamental missions An inclusive business model Yesterday The Mutual Health Funds At the heart of the collective negotiation process in the health insurance A participative governance. Historical background: a long tradition of Mutual Health Funds. Tomorrow What are the challenges?. 2

3 I. Introduction Towards a mutual learning perspective

4 I. Introduction Towards a mutual learning perspective Facing common challenges Access to healthcare for all (universal coverage), Ageing population, Migrations, Changes of family structures, Rising consequences of chronic diseases, mental diseases. Asserting principles and values based on solidarity Well-being of the population through social justice, social cohesion and equity, Promoting a fair and harmonious society / a smart, sustainable and inclusive growth Innovating in the management of the Social Security Promoting another economical development model. A mutual understanding perspective 4

5 II. The Belgian healthcare system (health insurance) in a nutshell

6 The main features of the Belgian health insurance (1) A multi-level governance o o Centralization and decentralization Shared responsibilities for healthcare Federal government Regulation and financing of the compulsory health insurance Legislation covering different professional qualifications Financing of hospital budget Registration of pharmaceuticals and their price control Federated entities Health promotion and prevention Maternity and child health care Financing of hospital investment Local governments Controlling the authenticity of the diplomas of health care providers Organization of on call duties for physicians during nights and weekend Organization of emergency care and public hospitals 6

7 The main features of the Belgian health The key features are insurance (2) A liberal view of medecine: mainly private (not-for-profit) provision of care, based on fee-for-service AND the healthcare providers enjoy complete freedom of diagnosis and prescription Patients are free to choose their healthcare providers, hospitals and Mutual Health Funds BUT compulsory enrolment to a Mutual Health Fund Competition between: *On the one hand Health care providers AND *On the other hand, Mutual Health funds ( social regulation) High quality care A compulsory health insurance system, based on reimbursement and with relatively high level of cost sharing (principle of solidarity) 7 Decision making based on negotiations (drafting the budget, purchasing of care based on collective contracting, collective management of compulsory health insurance system)

8 Social contributions of employees and employers EMPLOYEES (13,07 %) AND EMPLOYERS (33 to 41 %) = 66 % of the SS revenues State subsidies ( = 10,3%) + alternative financing ( = 23,7%) - indirect tax revenues NOSS (National Office for Social Security) Allocations between 7 functions NEO (National Employment Office) NPO (National Pensions Office) NOAV (National Office for Annual Vacation) NIHDI (National Institute for Health and Disability Insurance) NEFAO (National Employees' Family Allowances Office) FOD (Fund for Occupational Diseases) FAT (Fund for Accidents at Work) X Conferral of management Trade Unions or CAPAC Pensions NOAV or private funds Mutual Health Funds or CAAMI / SNCB NEFAO or family allowances funds Occupational Diseases FAT or private funds National Federations of Mutual Health Funds Mutual Health Funds (Regional) Beneficiaries

9 The main features of the Belgian health insurance (3) Payment mechanisms for the patient: o Mainly characterized by fee-for-service payment o Two systems of payment : - a reimbursement system, for which the patient pays first the full costs of services and then obtains a refund for part of the expense from the Mutual Health Fund (ambulatory care). - a third-party payer system, for which the Mutual Health Fund pays the provider directly for inpatient care and medicines purchased in pharmacies. *The patient is only responsible for paying any co-payments, supplements or nonreimbursed services; *Co-payments are equal for everyone with exception of patients with preferential reimbursement. 9

10 The main features of the Belgian health insurance (4) oa reimbursement system: Insured/Patient Full fee Healthcare providers Certificate Reimbursement = Official fee user charge Mutual Health Fund 10

11 The main features of the Belgian health insurance (5) oa third-party payer system: Insured/Patient Healthcare providers Copayment or user charge Payment Mutual Health Fund 11

12 The main features of the Belgian health insurance (6) A height of coverage 12

13 III. The Mutual Health Funds, an essential role in the Belgian health insurance

14 What is a Mutual Health Fund? The Mutual Health Funds play an essential role in the Belgian health insurance: NOSS/ NIHDI National Federation of Mutual Health Funds Mutual Health Funds Socially insured persons 2 types: o Private non profit making organizations with a public interest mission that are grouped into national federations according to their political or ideological background (5) - E.g. The National Federation of Socialist Mutual Health Fund o Public health insurance funds (2) o Auxiliary Fund for Health and Disability Insurance (CAAMI) o Health Public health insurance funds Insurance Fund of the Belgian Railways Group NMBS SNCB 14

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16 Missions Legally defined by law (sickness Fund Act 1990) Managing the compulsory insurance Organizing the complementary insurance Providing information and services in order to guarantee the quality and accessibility of care for all The compulsory health insurance is governed by law The compulsory insurance package and the social contribution rates are identical for all funds Any decision-making power BUT An important role: *Ensure the reimbursement of health care expenses and the provision of an alternative income in case of incapacity to work, *Control of conformity with the legal rules (advisory physicians), *Representatives for the patients collective negotiation process about fees, insurance coverage and regulatory structure, *Influence the decision-makers. The complementary health insurance is also governed by law The main purpose of the activities of mutual: to round off the Belgian health and access to care system by implementing and managing non-profit making services with a non-market logic. from one mutual health fund to another (another according to the needs expressed by members within the authorities). The Socialist mutual health fund: *Offer a wide range of benefits and services in various fields : costs which are not reimbursed by the compulsory health insurance, transport for patients, use of sanitary equipment, cost of convalescent treatment, etc. *A certain number of services are based around target groups: senior citizens, chronically ill patients, youth, women, or people with disabilities. Obligation to inform its members on health and social rights. *Legal capacity (Jurimut) to defend its members in court. The Socialist mutual health fund: *We have a large network of associations and specific services, such as disabled associations, federations of senior citizens, lifelong learning movements aimed at young people or women, services offering help and home care, and services entrusted with organising and coordinating initiatives in the field of education and health promotion. 16

17 To achieve these missions, the Socialist Mutual Fund has developed a large network o 11 regional federations o More than beneficiaries-members ( ) o o o o o o o o o o employees for our whole network (4 664 employees for the Socialist Mutual Health Fund) 36 centres offering home-delivered services 43 optical stores 65 clinics 5 general hospitals offering beds 23 equipment loaning centres 17 holiday/recovery centres 17 Family Planning Centres 8 schools of social promotion 418 social services centres 17

18 West Flanders (309) members East Flanders (311) members Antwerp (304) members Limburg (322) members National Federation UNMS NFSMHF (300) Brabant (306) members Walloon part of Picardy - Picardy Wallonia (315) members Walloon Brabant (305) members Liege (319) members Centre, Charleroi and Soignies (317) members Luxembourg (323) members Namur (325) members A broad geographical coverage Flemish Region: members / Walloon Region: members/ Brussels Region: members 18

19 To achieve these missions, the Socialist Mutual Fund has developed a large network o A network of branch offices (contact centers) contacts (per year) with beneficiaries-members 19

20 And is based on a range of distinctive values Primacy of the individual over capital ; Voluntary and open membership ; Democratic control by members conjunction of member users interests and the general interest ; Defense and implementation of principles of solidarity and responsibility ; Management autonomy and independence with regard to the authorities ; As a non profit orientated structure, surpluses are primarily intended for member services interests ; Inclusion of all members, regardless of his/her general health condition, age, gender or income. 20

21 An inclusive business model

22 An inclusive business model (1) We strive for the access to health for all. One goal: promoting a multidimensional coverage 22

23 The Mutual Health Funds At the heart of the collective negotiation process in the health insurance

24 To get deeper into one key function of the Mutual Health Funds (1) The stakeholders engaged in the consensus-building process: Federal Public Service (Ministry) Social Security Federal Public Service (Ministry) Social Security NIHDI NOSS Conferral of management Negotiator Mutual Health Funds Representatives for the patients Healthcare providers Healthcare institutions Insured/ Patients Regional Communities 24

25 To get deeper into one key function of the Mutual Health Funds (2) The negotiations and negotiations bodies: Minister of Social Affairs General management Committee for Healthcare Insurance General Council Sectorial negotiations Conventions and agreements commissions Preparatory negociations Technical councils 123 negotiations bodies with mandates (without the workgroups) Workgroups 25

26 A participative governance

27 A participative governance The acting powers of the Mutual Health Funds: 27

28 A participative governance The acting powers of the Mutual Health Funds: General Assembly Board of Governors Executive Committee Secretary General President Treasurer 28

29 Going «back to basics» Historical background: a long tradition of mutual health funds

30 19th century

31 Late 19 th century *Industrial Revolution *Rise of capitalism From the late 19th century to the beginning of the 20th century First step: a subsidized voluntary health insurance Mutual assistance Mutual benefit societies Mutual insurance Grouping into National Federations of Mutual Health Funds (1903) 1940: Second World War Government intervention Total: 3,000,000 insured 31

32 20th century 32

33 1943 *Second World War From the 20th century to the beginning of The Health Insurance Act of 9th August Introduction of a system of conventions and agreements between sickness funds and health care providers - The Social Security Act of 28 December Who? Employers and Trade Unions - What? Universal access to social security, the 21st century : A fixed budget for each subsector of healthcare is introduced. The Sickness Fund Act of 6 August A new legal framework setting objectives and tasks for the Mutual Health Funds 1994: The Mutual Health Funds are made partially financially accountable for their health care expenditure 2010: A new law regarding the provision of complementary services ( insurances >< other services). 33