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: – coopami@riziv.fgov.be

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

We welcome your questions, suggestions,

comments!

coopami@riziv.fgov.be