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Thomas Rousseau
NIHDI - COOPAMI 2
Thomas Rousseau
NIHDI - COOPAMI
A Belgian cooperation platform
www.coopami.org
20-06-2013
PROGRAMME
14.00 – 15.00 Université catholique de Louvain - Institute of Health and Society
Interview with an academic expert o Vincent Lorant
9.00 – 13.30
National Institute for Health and Disability Insurance (NIHDI)
The Belgian health care insurance o Thomas Rousseau
Financial accessibility in compulsory health care insurance
o Karlien Van Hellemont Lunch
14.00 – 15.00 Federal Public Service Health, Food Chain Safety and Environment
Role of the FPS Health and the Directorate-General for Healthcare facilities organization
o Pol Gerits
TODAY
TOMORROW
The Belgian health insurance
I. A comparison between Belgium and South-Korea
II. Social security in Belgium
III. Belgian Health insurance
I. Basic principles
II. Systems of payments
III. Financing
IV. Management
V. Recent reforms & future challenges
IV. Summary
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.
• Performance of the Belgian Health System. Report 2012.
• 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: – [email protected]
A comparison between Belgium and South-Korea
Belgium Republic of Korea
Surface area 30.528 km² 219.140 km²
Total population (2012) 11.035.948 50.004.441
• Age 0 – 14 15,9 % 15,1 %
• Age 15 - 64 66,1 % 73,1 %
• Age 65 and more 18,0 % 11,8 %
Gross national income per capita (PPP int. $) (2011)
39 374 $ 30 336 $
Unemployment rate: total labour force
7,2 % 3,4 %
A comparison between Belgium and South-Korea
A comparison between Belgium and South-Korea
2010 Belgium Republic of Korea
Life expectancy at birth 80,3 80,7
Total expenditure on health per capita (At
current prices and PPPs) 3 969 $ 2 035 $
Public expenditure on health (% of GDP) 7,97 % 4,10 %
Private expenditure on health (% of GDP) 2,57 % 2,95 %
Out-of-pocket expenditure on health (% of total expenditure on health)
19,4 % 32,1 %
Practising physicians (doctors) Density per 1 000 population
2,9 2,0
Hospital beds (Density per 1 000 population) 6,4 8,8
Sources: Key tables from OECD
Social security in Belgium
Social protection
Social security
Social assistance
Social protection
Presentation: • only on social security in the strict sense! • focus on the Belgian health insurance!
Contributif
Non-contributif
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
Insurance for accidents at work X
Insurance for occupational diseases X
Unemployment X
Insurance for medical care and benefits X X
Pensions X X
Family benefits X X
Annual vacation X
Bankruptcy X
Social Security in Belgium (3)
Expenses social security 2012 (000 €) Benefits/services 71.438.018 91,49%
Medical care 26.853.110 34,39%
Sickness benefits 6.223.082 7,97%
Old-age pensions 23.451.270 30,03%
Family benefits 4.954.574 6,35%
Accidents at work 197.930 0,25%
Occupational diseases 289.219 0,37%
Unemployment 9.456.662 12,11%
Bankruptcy 12.171 0,02%
Administration costs 2.258.057 2,89%
Other expenses 4.385.523 5,62%
Total expeses 78.081.598 100,00%
Social Security in Belgium (4)
• Who is collecting and managing the money for the social security?
2 collecting institutions
National Social Security Office (NSSO)
Salaried persons and civil servants
National Institute for the Social Security of the Self-Employed
(NISSE)
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
Sickness benefits 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)
National Social Security Office
Social contributions Government subsidies Alternative financing Why? limit government subsidies reduce employers' contributions
NIHDI
66%
10,3%
23,7%
Distribution of financial resources between sectors according to the real needs
Globalisation of the financial resources and management of incoming funds
NPO
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)
58,40% 23,15%
18,08%
0,37%
Financing
Social Contributions
Government subsidies
Alternative financing
Others
BASIC PRINCIPLES
The Belgian health insurance
Universal coverage
• 3 dimensions
> 99%
large package more than 8000 services
± 80% OOP
± 20 %
OOP
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
SYSTEMS OF PAYMENTS
The Belgian health insurance
Systems of payments (1)
Health care provider
Health insurance fund
Insured / Patient
Systems of payments (2)
• 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
Health care providers
Systems of payments (3)
• 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
Health insurance fund
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)
– health insurance fund
Systems of payments (5)
1. A system of reimbursement Health care provider
Health insurance fund
Insured / Patient
Reimbursement = Official fee – Co-payment
the full fee
certificate
Systems of payments (6)
2. A system of third party paying
insurance allowance
bill
Health insurance fund
Insured / Patient
Co-payment or user charge
Hospital
Pharmacie
FINANCING
The Belgian health insurance
The organization structure of the Belgian health care system
FPS Health
Health insurance
funds
NIHDI
Health care provider ---------------------------
Hospitals
Financial flow
Supervision and/or regulation
Services
NISSE FPS
Social Security
Insured / Patient
Minister of Social Affairs and Public Health
NSSO
Financing of compulsory health insurance
SOURCES 2012 (millions €) %
Social contributions + government subsidies + alternative financing
26.493.101 91,14%
Retirement contribution 951.013 3,27%
Car insurance 474.282 1,63%
Fire insurance 179.660 0,62%
Tax on profit of pharmaceutical companies
262.940 0,90%
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
Reimbursement of health care services 26.853.110
Internationale conventions 637.268
Administration costs health insurance funds 891.951
Administration costs NIHDI 102.658
Other expenditures 583.012
total expenditures 29.067.999
Social health Insurance expenditures 2012 (000 €)
Partial objectives
29,09%
21,31% 17,70%
9,24%
4,67%
4,46%
3,28% 2,70%
2,43%
2,18% 1,60%
0,98% 0,17%
0,13% 0,06%
Médecins
Hôpitaux
Médicaments
Maisons de repos
Infirmiers
Solde
Dentistes
Implants
Kinésithérapeutes
Rééducation
Dialyse
Bandagistes et orthopédistes Audiciens
Opticiens
Health care sectors
Doctors
Hospitals Pharmaceutical products
How do we fix yearly
the reimbursement
budget of health care ?
Fixation of the budget
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
Budget T-1 + Growth norm(%) + Inflation T (%) ------------------------------------- = Budget T
Health Insurance Act:
The real growth norm
1995 - 2000 1,50%
2001 - 2004 2,50%
2005 - 2011 4,50%
2012 - 2013 2,00%
2014 - 3,00%
Evolution
Fixing the annual global budget objective is therefore not subject to a vote in parliament, but the parliament can change the growth norm
Financing of Health insurance fund
70% of the expenditures
30% on basis of a distribution key
NIHDI
Insured / Patient (± 11.000.000)
Health insurance funds
MANAGEMENT
The Belgian 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)
Federal Public Service Health Ministry NIHDI
Public social security institution
• Preparation and realisation of public health policy The organization and financing of health care institutions The organization of health professions The emergency medical
• 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)
CEO &
Deputy CEO
Health care Departement
Benefits Department
Medical Evaluation and Inspection
Department
Administrative Inspection
Department
General Support Departments
Fund for Medical Accidents
Cell
Communication
Cell
Modernisation
Cell Datamanagement
Cell Expertise & COOPAMI
Safety information Prevention
service
Internal audit
General Managment Committee
± 1350 staff members
• Departments
The collective negotiation process in the health insurance (1)
• Stakeholders
NIHDI
Government
Salaried employees and self-employed
workers
Health insurance funds
Health care providers
Employers
The collective negotiation process in the health insurance (2)
• The object
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)
Workgroups
Technical councils
Conventions and agreements commissions
General Council Committee for Health Care Insurance
Minister of social affaires • Negotiation bodies
Sectoral negotations
Preparatory negotations
General management
Budget Control Committee
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
Health Care Insurance Committee
General Council
Conventions and agreements commissions
Mission
Determination of needs
Carries out technical estimates
Identification of potential economy measures
Suggestion of a global budget objective +
its breakdown into partial objectives
Decision on a global budget objective +
its breakdown into partial objectives
Negotiation of conventions and agreements
RECENT REFORMS & FUTURE CHALLENGES
The Belgian health insurance
The objectives of the Belgian health care system
Maintaining financial
sustainability
Assuring health care quality
Increasing accessibility
See next presentation
Maintaining financial sustainability (1)
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
5
1980-1990 1990-2000 2000-2007
Trends in health expenditure in Belgium, 1990–2007
Total health expenditure
GDP
Maintaining financial sustainability (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 – (Aging population)
• 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
Maintaining financial sustainability (3)
Year initiativessavings
measuresnet 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
New initiatives and savings measures in health care
Maintaining financial sustainability (4)
• Permanent audit reports :
– Systematic reporting of the evolution of expenditure for each sector
• Provisional fund for pharmaceuticals to compensate for budgetary excess
• Measures to reduce pharmaceutical prices and to promote the prescription of low-cost drugs
• Lump sum payments (GP’s, hospitals, home nursing, …)
Maintaining financial sustainability (5)
Assuring health care quality (1)
• Making health care providers accountable – Improving prescribing behaviour
• Additional feedback on prescription • Recommendations for pharmaceutical products
– Financial incentives
• GP’s: transforming fee for service system into a mixed financing scheme • Pharmacists: new system of remuneration • Hospitals: developing DRG-financing and lump sum financing for pharmaceutical
hospital care
– Medical evaluation and inspection departement • controlling the misuse of diagnostic and therapeutic freedom, related in particular
to over-consumption. • evaluating the reimbursement of medical care consumption in light of the
measures taken to prevent and detect misuse • providing information to health care providers, such as recommendations on good
medical practice and indicators of over-consumption
Assuring health care quality (2)
• Strengthening primary care – Expanding the preventing role of GP (Global Medical File) – Promoting grouping of GP’s (Impulseo II)
• Promoting the integration of health services and multidisciplinarity – Patient pathways (chronic renal failure and types 2 diabetes) – Therapeutic projects in mental health care – National Cancer plan
• Assessing the performance of the health system – Regular reporting on health system performance in Belgium
Assuring health care quality (3)
The long-run challenge: accommodating increasing expenditures
Low expenditures High
expenditures
Growth of private
alernatives Further extension of the collective
system
• What to do?
• Increasing cost-awareness of the players • Increasing the efficiency • Increasing the prevention • Rewarding quality • Improving the information system
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