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36 Economic crisis, health systems and health in Europe: country experience
1 July 2014. The Sixth State Reform is first and foremost a political agreement
with a substantial transfer of powers in health care to the communities. The
aim of the transfer is to have a more rational distribution of tasks, but the issue
of conflicting incentives between government levels has not been addressed
(OECD, 2013a).
All of these background factors forced policy-makers to be more explicit about
choices. Safeguarding and improving financial accessibility to high-quality
health care was the first concern. A second priority was to ensure a sufficiently
large workforce in the health care sector. The fact that budget proposals for
2012 and 2013 had to be formulated within tight budgetary margins raised
awareness among stakeholders that measures to increase health care efficiency
were inevitable. In that sense, several agreements (between sickness funds and
health care professionals) contained structural measures (some not implemented
yet) based on evidence-based medicine instead of the former linear cuts in
indexation. Examples include the revision of the Belgian fee schedule (to take
place in the years to come), whereby fees become better correlated with realtime
investment and costs; measures to increase the attractiveness of general
practice; the revision of financing mechanisms for medical imaging, dialysis and
emergency care; the development of DMPs for chronic diseases; emphasis on
preventive and conserving dental care; and the promotion of INN prescribing
(see also section 3).
For 2013 and 2014, priorities continued to be accessibility and quality of
care. An important additional objective is financial transparency, especially
in the ambulatory sector. Concrete initiatives include proposed new laws to
increase accessibility to drugs for unmet medical needs and to introduce greater
transparency for ambulatory care costs. The major breakthrough regarding
transparency will be that, from 2016 onwards, the health care certificate that
patients receive when they visit a doctor will mention explicitly the supplement
paid over and above the official tariff, the latter equalling the sum of the
reimbursed amount and the co-payment.
The pressure on government budgets has also breached certain taboos, for
example regarding the fight against social fraud, the monitoring of outliers in
dental care, the lack of transparency in supplements paid by patients to medical
doctors, the explicit comparison of the quality of care in hospitals, and so on.
Measures have been applied in the dental care sector, for example, to reduce
expenditure because a small group of outliers was exploiting the system, albeit
in a legally correct manner as they could not be prosecuted for their excessive
activities. 16 This was frustrating to the larger group of responsible dentists
16 To illustrate the extent of the excesses: simulations showed that 31 dentists (0.4% of all dentists) accounted for 1.35%
and 1.30% of total expenditure for dental care in 2010 and 2011, respectively.