Pay for Quality

110 Pay for Quality KCE Reports 118
Belgium is a country with a high access level of patients to healthcare and almost
universal compulsory health insurance coverage (99%). Currently the level of gate
keeping is minimal. Patients are free to chose which provider (GP, specialist, hospital)
they consult, without restrictions. The basic right to health care has been set out in the
Belgian Constitution.
Patients participate in healthcare financing via co-payments, for which the patient pays a
certain fixed amount of the cost of a service, and via co-insurance, for which the patient
pays a certain fixed proportion of the cost of a service (10 to 40%). A maximum of outof-pocket
expenses is safeguarded.
Competition in the Belgian health system operates mainly through the competition for
patients between providers and the competition for members between sickness funds.
A typical characteristic of the Belgian health system is the participation of several
stakeholders in its management. An important part of the health system is regulated by
national collective agreements made between representatives of health care providers
and sickness funds.
Since the mid 1990s attention for the quality of healthcare in Belgium has increased.
Quality control is applied by the government through accreditation of healthcare
institutions (Hospital Act), accreditation of providers, peer review, audit and visitation.
Hospitals report to the federal government (colleges of physicians) on their quality
status on a yearly basis. The regional government of Flanders requires healthcare
institutions to implement a quality manual, plan and evaluation cycle as part of
accreditation conditions. In addition, specific campaigns address issues such as hand
hygiene, antibiotics use, etc.
Based on the conclusions and recommendations of the previous chapters the Belgian
healthcare system, payer, provider and patient characteristics seem to fit with P4Q in
the following way:
There is strong evidence (next to international expert support) of the importance of
the uniformity of the P4Q design, independent of the identification of P4Q initiators and
coordinators. In this respect the concurrent levels of regional and national healthcare
jurisdictions may pose a threat. The same risk is present at the level of the six sickness
funds as purchasing/payer organizations. They are however united as part of RIZIV
representation. With regard to P4Q implementation in Belgium a clear consensus
based, all stakeholder inclusive approach is recommended, including complementation of
the regional and federal level. This enables a combined centralized and decentralized
(e.g. local priority setting based on room for improvement) decision making process.
Multiple incentive programmes at the payer level should be aligned.
With regard to the level of competition the low level of patient volatility in Belgium will
support P4Q on the one hand. P4Q is not reinforced by consumer driven healthcare on
the other hand.
Incentive theory states that P4Q targeting underuse fits with a dominant FFS payment
system. It’s therefore a reinforcement of the P4Q effect on this type of targets. Vice
versa it may pose a threat to the P4Q effect on overuse targets. However, many of
these overuse targets (medical imaging, clinical biology, etc.) are increasingly reimbursed
as fixed payments, which diminishes this threat.
In terms of provider characteristics specifically for hospital care the current focus of
legislation, financing and quality management at the organizational level may pose a
threat to P4Q targeting individual providers and/or team members. Such direct
targeting in Belgium requires specific attention in P4Q regulation.
Finally, with regard to patient characteristics the use of case mix adjustment at various
levels of the Belgian healthcare system can be leveraged. However, more specific
attention for the patient’s role is needed (equity, knowledge and involvement,
experience of care, behavioural patterns, etc).