A Belgian cooperation platform www.coopami.org Thomas Rousseau NIHDI - COOPAMI Thomas Rousseau NIHDI 14-01-2013 - COOPAMI 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
What i m not going to talk about
Usefull information Report of the European Observatory on Health Systems and Policies: Gerkens S, Merkur S. Belgium: Health system review. Health Systems in Transition, 2010. Websites: National Institute for Health and Disability Insurance: ww.riziv.fgov.be The B. Health Care Knowledge Centre: www.kce.fgov.be FPS Social Security: www.socialsecurity.fgov.be E mail for questions: coopami@riziv.fgov.be
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
The Belgian health insurance 1. SOCIAL SECURITY IN BELGIUM
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
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
Social Security in Belgium (3) Expenditures of social security 2010 Soins de santé 27% 24% TOTAL: 94.122.580.923 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
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
1.Salaried persons
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
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
2. Self Employed persons
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 12.597,43 692,86 per quarter Between 12.597,43 and 54.398,06 22% of net professional income Between 54.398,06 and 80.165,52 14.16% of net professional income More than 80.165,52 0
Self Employed persons (2) 18,08% 0,37% Financing Social Contributions Government subsidies Alternative financing 23,15% 58,40% Others
The Belgian health insurance 2. FINANCING OF THE COMPULSORY HEALTH INSURANCE
Financing of compulsory health insurance SOURCES (millions ) % Social contributions + government 26.493.101 91,14% subsidies + alternative financing Retirement contribution 951.013 3,27% Car insurance 474.282 1,63% Fire insurance 179.660 0,62% Tax on profit of pharmaceutical 262.940 0,90% companies Complementary hospital insurance 124.564 0,43% Internationale conventions 382.163 1,31% Other sources 200.276 0,69% Total 29.067.999 100%
Expenditures Social health Insurance expenditures 2012 (000 ) Reimbursement of health care services 26.853.110 Internationales conventions 637.268 Administration costs sickness funds 891.951 Administration costs NIHDI 102.658 Other expenditures 583.012 total expenditures 29.067.999
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
Fixation of the budget How do we fix yearly the reimbursement budget of health care?
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
Fixation of the budget Health Insurance Act: Budget T 1 + Growth norm(%) + Inflation T (%) = Budget T
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 1995 2000 1,50% 2001 2004 2,50% 2005 2011 4,50% 2012 2013 2,00% 2014 3,00%
New initiatives and savings measures New initiatives and savings measures in health care Year initiatives savings measures net effect cumulative net effect 2004 121.770 221.988 100.218 100.218 2005 44.108 399.761 355.653 455.871 2006 270.836 132.172 138.664 317.207 2007 156.846 38.016 118.830 198.377 2008 415.356 0 415.356 216.979 2009 191.842 139.317 52.525 269.504 2010 393.955 201.825 192.130 461.634 2011 109.883 100.000 9.883 471.517 2012 6.505 494.857 488.352 16.835 2013 696 269.816 269.120 285.955
The Belgian health insurance 3. SYSTEMS OF PAYMENTS
Systems of payments (1) Insured / Patient Health care provider Health insurance fund
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
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
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
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
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
Financing of Health insurance fund 70% of the expenditures NIHDI 30% on basis of a distribution key Health insurance funds Insured / Patient (± 11.000.000)
The Belgian health insurance 4. Basic principles of the Belgian health insurance
Universal coverage 3 dimensions ± 80% > 99% 11.000 Nomenclature codes
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
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
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
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
The Belgian health insurance 5. The management of the health insurance
The management of the health insurance NIHDI National union of health insurance funds Health insurance funds Insured / Patient
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
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
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
Stakeholders The collective negotiation process in the health insurance (1) Government Employers NIHDI Salaried employees and self employed workers Health care providers Sickness funds
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
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
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
The Belgian health insurance 6. THE FUTURE?
The objectives of the Belgian health care system Maintaining financial sustainability Increasing accessibility Assuring health care quality
The long run challenge: accommodating increasing expenditures (1) 5 Trends in health expenditure in Belgium, 1990 2007 4,5 4 3,5 3 2,5 2 Total health expenditure GDP 1,5 1 0,5 0 1980 1990 1990 2000 2000 2007
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
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% 1997 2001 2004 < 750 euro 750 1000 euro 1001 1500 euro 1501 2500 euro > 2500 euro Total Source: KCE, 2010
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
The Belgian health insurance 7. SUMMARY
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
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