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38 Economic crisis, health systems and health in Europe: country experience
were evaluated as being successful: a large number of patients participated in
the DMPs and the quality of care was considered to be improved. However,
as it was not possible to assess the impact of the DMPs on patient outcomes
because the observation period was too short, it was decided not to extend the
system of DMPs to other target groups.
Better collaboration has, however, been achieved in the area of data analysis and
policy research. Belgium has very rich databases on health care consumption and
expenditure (excluding fee supplements in the ambulatory sector) but limited
resources for the analysis of these data. Because of this and the perceived need
to have a stronger evidence base (based on real-life data) for policy changes to
cope with the crisis, successful collaborations have been set up between research
departments of different institutions, such as the Intermutualistic Agency, the
Health Care Knowledge Centre, the RIZIV and the Scientific Institute of
Public Health.
5.3 Implementation challenges
A major challenge to implementing changes in the Belgian health system is dealing
with the fragmented structure of the system. Subsectors are vertically divided into
several segments (pillars; zuilen) and it is hard to breach the boundaries. The FFS
schedule is a list of fees and tariffs for isolated health care activities. It is still the
major remuneration system for physicians. The FFS systems contain incentives to
provide more services to increase incomes, thus mitigating against the efficient use
of resources. In addition, the fees are no longer a good reflection of the real costs
for many procedures because they have never been modified despite evolutions in
science and medical practice (RIZIV, 2013d). Therefore, the fee schedule will have
to be revised. Along with this revision, hospital financing may be reconsidered
and both might be more effectively coordinated, particularly from the perspective
of integrated care. From this perspective, collaboration between hospitals may
also be a challenge. Currently, such collaboration is limited and most hospitals
wish to provide all services.
Another challenge will be the possible resistance of stakeholders to measures
that are designed to maintain accessibility and quality of care but which might
restrict therapeutic freedom and freedom of choice. This relates to additional
measures to increase the efficiency of health care and avoid inappropriate use,
but also to increase transparency in (supplementary) charges to patients in the
ambulatory sector, which is currently still a "black box" for both patients and
policy-makers.
Belgium has rich data on health care expenditure and consumption. However,
some data are old and updates are not regular enough to allow swift reactions.
This applies, for example, to hospital clinical data (available with a delay of