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Chapter 1 | The impact of the crisis on the health system and health in Belgium 27 Table 1.7 Co-payment pressure in Belgium for physician fees with and without the maximum billing system Co-payments as a percentage of total fee expenditure, excluding supplements Without maximum billing With maximum billing 2007 8.66 7.20 2008 8.60 7.32 2009 8.54 7.23 2010 8.22 6.85 2011 7.91 6.60 2012 7.80 6.54 Source: RIZIV, 2012. Medical houses Medical houses are primary care centres where a team of GPs, physiotherapists and nurses offers medical care free of charge to patients. The RIZIV reimbursement takes the form of a lump sum per registered patient (riskadjusted capitation payment), paid directly to the providers working in the medical house. In contrast to their colleagues, health care providers are not paid on a FFS basis with co-payments from patients. Also in contrast to single-provider practices, patients do not have to pay the full fee upfront and claim reimbursement afterwards. This reduces financial barriers to access to health care services. In general, medical houses are situated in disadvantaged neighbourhoods. However, with the crisis, they are becoming increasingly important. Patients still have to pay for pharmaceuticals, bandages and other nursing material. When a patient goes to another provider (e.g. a GP not working in the medical house), this service is not reimbursed by the RIZIV (except for out-of-hours consultations). The number of medical houses and the number of people registered with them has increased more rapidly in Belgium since 2003, and this trend continued after the onset of the crisis. In 2008, there were 88 medical houses with just under 189 000 registered patients; in 2011there were 119 medical houses with 250 075 registered patients. On 30 June 2012, there were 129 medical houses with about 274 000 registered patients, representing a 10% increase over 2011 (RIZIV, 2013b). Consequently, the RIZIV expenditure for medical houses also increased rapidly, from €25.9 million in 2003 to €92.8 million in 2012, with the greatest increase for nursing services. The increase cannot, however, be attributed to the crisis.
28 Economic crisis, health systems and health in Europe: country experience Hospital care The Belgian Government has taken several measures to reduce OOP costs for hospitalized patients. Three major measures were taken: • protection against room (2010) and fee (2013) supplements charged by hospital physicians for patients staying in a room with two or more beds, independent of the qualification of the physician or the status of the patient, except for non-contracted physicians in day care; • better reimbursement of medical devices and implants (since 2008, but the effects have been more pronounced since 2012); and • increased transparency on the costs charged to patients (2013). These measures have had an impact on patients' OOP costs associated with hospitalization. There has been an increasing divergence between the cost of a hospital stay in a single room and that for a stay in a room for two or more people. Physicians and hospitals reacted to the tightening of the regulation by increasing supplements where they were still allowed: between 2004 and 2011 fee supplements for the members of the Christian Sickness Funds increased each year by 5.4%. Nevertheless, the overall cost of a stay in a single room has remained more or less stable in recent years, because the increase in fee supplements was compensated by a decrease in material supplements (Crommelynck, Cornez & Wantier, 2013; Schokkaert & Van de Voorde, 2013). There is, however, large variation among hospitals, with a small fraction of hospitals charging fee supplements that amount to 400% of the official tariff (Crommelynck, Cornez & Wantier, 2013; Laasman, 2013). Hospitals charging large fee supplements are mainly located in Brussels and to a lesser extent in the Walloon Region. For people without preferential reimbursement, supplements in 2012 amounted to an average of €1100 in Flanders, €1490 in Wallonia and €2384 in Brussels. Fee supplements, and to a lesser extent room supplements, were responsible for these striking differences. Population with preferential reimbursement An analysis of the data of the Christian Sickness Funds showed that between 2009 and 2011 15% more people became eligible for preferential reimbursement (Christian Sickness Funds, 2012). The socialist sickness funds made similar observations among their members. Since the economic crisis, the proportion of members from the socialist sickness funds with preferential reimbursement status, including those with Omnio-status, increased from 15% in 2006 to more than 23% in 2012 (Laasman, 2013). Assuming that the
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Chapter 1 | The impact of the <strong>crisis</strong> on the <strong>health</strong> system <strong>and</strong> <strong>health</strong> in Belgium<br />
27<br />
Table 1.7 Co-payment pressure in Belgium for physician fees with <strong>and</strong> without the<br />
maximum billing system<br />
Co-payments as a percentage of total fee<br />
expenditure, excluding supplements<br />
Without maximum billing With maximum billing<br />
2007 8.66 7.20<br />
2008 8.60 7.32<br />
2009 8.54 7.23<br />
2010 8.22 6.85<br />
2011 7.91 6.60<br />
2012 7.80 6.54<br />
Source: RIZIV, 2012.<br />
Medical houses<br />
Medical houses are primary care centres where a team of GPs, physiotherapists<br />
<strong>and</strong> nurses offers medical care free of charge to patients. The RIZIV<br />
reimbursement takes the form of a lump sum per registered patient (riskadjusted<br />
capitation payment), paid directly to the providers working in the<br />
medical house. In contrast to their colleagues, <strong>health</strong> care providers are not<br />
paid on a FFS basis with co-payments from patients. Also in contrast to<br />
single-provider practices, patients do not have to pay the full fee upfront <strong>and</strong><br />
claim reimbursement afterwards. This reduces financial barriers to access to<br />
<strong>health</strong> care services. In general, medical houses are situated in disadvantaged<br />
neighbourhoods. However, with the <strong>crisis</strong>, they are becoming increasingly<br />
important. Patients still have to pay for pharmaceuticals, b<strong>and</strong>ages <strong>and</strong> other<br />
nursing material. When a patient goes to another provider (e.g. a GP not<br />
working in the medical house), this service is not reimbursed by the RIZIV<br />
(except for out-of-hours consultations).<br />
The number of medical houses <strong>and</strong> the number of people registered with them<br />
has increased more rapidly in Belgium since 2003, <strong>and</strong> this trend continued<br />
after the onset of the <strong>crisis</strong>. In 2008, there were 88 medical houses with just<br />
under 189 000 registered patients; in 2011there were 119 medical houses<br />
with 250 075 registered patients. On 30 June 2012, there were 129 medical<br />
houses with about 274 000 registered patients, representing a 10% increase<br />
over 2011 (RIZIV, 2013b). Consequently, the RIZIV expenditure for medical<br />
houses also increased rapidly, from €25.9 million in 2003 to €92.8 million<br />
in 2012, with the greatest increase for nursing services. The increase cannot,<br />
however, be attributed to the <strong>crisis</strong>.
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