Proposition 50K1905

Projet de loi portant des mesures en matière de soins de santé.

General information ¶

Submitted by

Groen Open Vld Vooruit PS | SP Ecolo MR Verhofstadt Ⅰ

Submission date

July 3, 2002

Official page

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Status

Adopted

Requirement

Simple

Subjects

elderly person doctor medicine health costs organisation of health care paramedical profession medical institution health insurance

Voting ¶

Voted to adopt

Groen Ecolo LE PS | SP Open Vld MR

Abstained from voting

CD&V N-VA FN VB

Party dissidents ¶

• Ferdy Willems (N-VA) voted to adopt.
• Jean-Pierre Grafé (LE) abstained from voting.

Contact form ¶

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Discussion ¶

July 12, 2002 | Plenary session (Chamber of representatives)

Full source

The Joint Committees for Public Health and Social Affairs discussed the present bill during the meetings of 2, 3, 5 and 10 July last year.

To this bill was originally also added the bill of Mr Vandeurzen and consorts, namely document 50/1294/001 amending the Hospital Act concerning the collection of payments owed by hospitalized patients. However, this bill was disconnected from the bill with the mutual agreement of the committee members and this after the minister's promise to hold a debate on this in the committee at the latest in November 2002.

Ministers Vandenbroucke and Aelvoet explained the draft. I will go over this for a while in bird flight.

Chapter 1 contains a number of provisions that form part of a future plan for general medical care.

Chapter 2 covers the fields of clinical biology, medical imaging and dialysis.

Chapter 3 introduces measures to eliminate practical differences in standard procedures carried out in the hospital.

Chapter 4 aims to enable the financing of experimental prescription models. Chapter 5 introduces an administrative fine for healthcare providers who fail to comply with statutory or conventional fees.

Chapter 6 contains a set of financial provisions.

Chapter 7 sets out provisions with a view to the introduction, from 2003, of a new financing system in the restrooms and in the rest and care homes.

Chapter 8 deals with the adjustment of the representation in the RIZIV organs.

Chapter 9 deals with healthcare renewal projects.

Chapter 10 contains a number of provisions of different scope.

Title III creates a legal framework enabling the advisory physicians of insurance institutions to participate in the monitoring of the effectiveness of health care in hospitals.

To this end, it is registered that consulting physicians at the intermutual level cooperate in an audit coordinated by the new FOD Public Health, Food Chain Safety and Life Environment. The assignments will be progressively expanded, starting with the validation and registration of the MKGs. In a next step, the evaluation of the admission policy will also be initiated followed by an evaluation of the medical practice. It shall also provide for an intermediate evaluation of the functioning of this control system. This evaluation will take place in the multi-party structure which is also responsible for the evaluation of the medical practice. The finality of the data transmitted to the counseling physician is limited to a control assignment that is always carried out in intermutual connection. In this chapter, the draft also provides for a scheme of compensation to the doctors of the scheme, which deduces certain differences between actual expenses and reference expenses from the amounts charged to the health insurance. The draft also provides for the establishment of a committee per hospital in order to ensure financial transparency of the cash flows within the hospital. This committee shall consist of a delegation of the administrator and a delegation of the medical council.

The second chapter amends the law of 29 April 1996 concerning social and various provisions. In particular, it concerns the consultation structure which is renamed the "multiparty structure on hospital policy" or, in short, the "multiparty structure". With regard to the hospital, an advisory power is given, in particular with regard to financing, recognition standards and programming criteria. The competence to evaluate the medical practice is also clarified.

In the general discussion, all members agreed that the proposed measures related to the strengthening of the first line within the framework of the future plan for general medicine were extremely positive and will contribute to breaking the negative spiral in front of the medical profession.

There is the introduction of a availability fee for doctors in waiting service, which of course will also automatically lead to the rationalization of the urgency, the granting of a contribution for the electronic management of the medical records and the introduction of a fee for the management of the global medical record.

For other necessary measures, the Minister shall refer to the consultation with the doctors that may be continued in this regard. He announced that the Royal Decree on the recognition of the family physician circles will also be published soon. A sum of 2.5 million euros was allocated for this purpose.

As regards the measures on clinical biology, medical imaging and dialysis, it was also favorable to the inclusion of daily hospitalization in the sub-budget for the benefits granted to rightholders hospitalized in a hospital.

In connection with the introduction of the reference amounts, some members fear tensions between hospital managers and doctors, and some also wondered that the APR/ADR scheme was explicitly incorporated in the law. However, the minister pointed out that a recovery mechanism was explicitly included in the law in order to be able to start quickly. In the future, further implementing decisions will be made by the executive power.

Several members pointed out the pressing problem of funding for elderly care institutions and the need for sufficiently qualified personnel. The project provides the legal basis for the introduction in the future of an envelopment system in the rest and care homes for the elderly and in the ROB. It is intended to establish the total budget on the basis of the aggregate sum of the sub-budgets per institution according to fixed criteria and on the basis of a case-mix of appropriations.

Everyone also agreed that the influx to the emergency services should be limited provided that great attention is paid to the problem of the socially weak and the specific situation in the major cities.

With regard to the establishment of the multi-party structure, several members raised concerns about the establishment of a new body. Nevertheless, it was recognized the importance of the bridge that this brings between the RIZIV and the FOD Public Health.

During the article-by-article discussion, a whole series of amendments were submitted. After that, the vote was passed. A second reading of the global design was also held. During the second reading, the committee confirmed the previous vote on the amendments adopted in the first reading. All the amended and improved provisions submitted to the committees were eventually adopted by 18 votes in favour and 2 abstentions. This report was also unanimously approved. Here is the report of our work.

During the general discussion, the speakers will be Mr Goutry, Mrs Descheemaeker, Mr Mayeur, Mrs Avontroodt, Mr Leterme and Mr Bacquelaine.

Dear colleagues, for those who have just arrived, I remind you that I have received amendments from some colleagues on the Bill No. 1907. I will distribute them to you. They will be sent back to the committee. Leterme would like to get acquainted first. I will ask Mrs. Avontroodt, Chairperson of the Commission, to convene her committee around noon to examine these amendments as well as those of Mrs. Trees Pieters.

In the meantime, I have received the amendment from Ms. Descheemaeker and consorts, even in two copies. I would also like to round up the other amendments and then maybe even take the word on the referral to the committee of the relevant bill.

I suggest you do that later.

Following Mr. Goutry’s speech, of course.

Mr. Speaker, Mr. Minister, colleagues, first of all, I would like to thank the rapporteur, Mrs. De Meyer, for the great work she has done in order to deliver to us this morning, in such a short time and at such a high meeting speed, a properly embedded report via De Post. Mrs De Meyer, this is an achievement in itself and I would like to sincerely congratulate you on this. This also applies to all those who have helped in some way. This is especially true for the printers, who probably yesterday — during the Flemish holiday — had to have the printing office run in order to get this report on the banks today.

I still have something from my heart. I will not stay there for long. It is regrettable that, like last year, at the very end of the sitting time, we have to harvest all kinds of witchtours in order to be able to finish our normal work. Normally it is our task — in addition to controlling the executive power — to be engaged in legislation throughout the year. We are always willing to do so, full of collegiality and constructivity, but if we only have one day to prepare a bill, we are still not working in an orderly way. Furthermore, the State Council has had to hurry to have the opportunity for four weeks to discuss, discuss and formulate the comments on the draft. They needed four weeks to do so, which — I can judge the design — is not exaggerated at all. We ourselves — the legislators — must do this in one day, including the opinion of the State Council, all texts and references to the legislation. As everyone knows, the legislation on health insurance and everything related to it is becoming more and more complex.

We also noticed this during the discussions. Not seldom additional information questions were asked in order to be able to understand the whole correctly and place it correctly. Their

I regret this in any case. We also hope that this has been the very last time — the legislature will not take so long anymore — and that the next bills will reach us at a more convenient time.

A second note about the design is that it also contains many powers to the King. Of course, one can say that it is a fairly technical legislation, with a lot of modalities to be regulated later, and that one can never expect that all this is regulated in the law. I also made this comment during the general discussion; you partially rejected it, Mr. Minister. Then I looked at it quietly. Fortunately, the report provides some clarification on a number of rules, but that binds us to nothing. The report only accompanies the texts of the draft, but can never be relevant in terms of intentions and future. How often should we not ask for an explanation in order to know what is required of us? You demand that we give a full authority by way of speech, so that the minister can elaborate the matter or the King can determine them. With regard to the broader intentions contained in the law, this becomes, of course, difficult, especially for the opposition, which must always be critical and vigilant. Their

Mr. Minister, this too — we have already exchanged thoughts on it — could be a sort of emanation of the increasing urge to centralize everything that on the budgetary level, i.e. revenue and expenditure, relates to health insurance, health care.

There seems to be a tendency to dirigism and centralism. Everything seems to be a lot more rigid. Thus, various types of committees are established, while the Minister is empowered to determine the detailed rules, even in relation to the composition of those committees. We hold our hearts for it!

This is a paradox, and we will ⁇ have to discuss this in the future. I explain myself more closely. On the one hand, there is now a very large budget in healthcare, with the pressure to further expand the budget still increasing. On the other hand, the Minister must be able to manage and control his budget. Of course, I understand that the needs are infinite and the resources end. Both reconciling and prioritizing — and thus making choices — is not an easy task. Of course, we follow that logical reasoning.

The question then arises how we will control one and the other. In my opinion, there are two models for this. One is that we try to make everyone as responsible as possible. You have already taken steps, Mr. Minister. The other is that we define responsibilities in a logical and consistent way. We are all facing the same task; we must make choices in view of the finite budget and we will consult with each other in a democratic way to come to a certain decision.

There is, of course, the pressure of the budget: the accounts must be blown. We have repeatedly pointed out the excess of the budget. You answered that you really needed to take over the expenses and that you needed instruments to detect excesses immediately via flashlights, after which recovery mechanisms take action, and so on.

My group has always supported you. If I were in your shoes, I would also find it necessary to have the tools to keep the finger on the wrist and to continuously track the income but ⁇ the spending so that the government is able to act immediately and take certain measures. Mr. Minister, it will not be easy in the future to find a balance between, on the one hand, the short-term policy – every year – to ensure that the package remains balanced and has sufficient resources, and, on the other hand, the pressure arising from the difficult process of accountability, consultation and democratization. The paradox is both trying to control.

Mr. Minister, with a knowledge center that centralizes and processes all data like a kind of large planning agency that maps everything and therefore also possesses all knowledge, you are at risk of the knowledge being found too much in an expert center and not being sufficiently tested by society, including in making choices. If you are the first to rely on the data of the Expert Center and on the opinions of the multi-party to define your policy, it is likely that you will be increasingly distracted from the choices that society wants to make and about which Parliament wants to have its voice. The paradox of controlling the spending of the health care facilities by, on the one hand, being able to quickly play the ball by having accurate data and profiles to detect aberrations and, on the other hand, the interpretation of the data is an important debate that will need to be conducted in the future.

I agree with this 100%.

But who does it ultimately? Who interprets that? Who makes the decisions? To what extent are they discussed and shared? How will this mechanism work? Let’s be honest, so far it has been mainly invested in one aspect, namely the collection of data, the ability to quickly play on the ball, the launch of flashlight systems and corrective mechanisms, the accurate monitoring of spending. I think you have done a meritorious job in this area. It is, of course, still a bit of coffee thickness, because it is much darker for us to see what system you want to build for the future to make the resulting decisions.

Chinese therapy is not a good example. The decision on kinesiotherapy has been taken quite dirigently. In the government statement in October 2001, you announced that you wanted to do something serious with the budget of kinesiotherapy, to which you would also link plans. By the end of February 2002, this reform had to be completed. In October, however, you already knew how much you would benefit from those reforms. Then we asked for it. You answered that you did not actually rely on anything, but that you are doing a simulation with certain results resulting. Afterwards, it turns out that you have a reform plan in your closet.

Then a kind of fake consultation begins. You should be careful with that, I think. The Chineseists are already first overwhelmed with the plans, to take or to let be. In addition, they are then placed on an impossible task. The professional groups are somewhat fragmented. They are not just that kind of work. They are not just about implementing reforms or thinking about policy work. You then give them two months of chance, with the hot breath of the ready-made plan in their neck, to try to get out of it. If they didn’t get out, you would decide for yourself. That has happened, despite everything and possibly despite all your good intentions. I have always found a reform in this area useful or meaningful. However, the way that the reform has been carried out has, to this day, brought about great chaos. For the sake of intellectual honesty, I don’t even want to use the press reports that some Chineseists are on the ground because of a large decline in clientele. I don’t want to talk about that, because I think there is always a difficult period.

The way it happened is not a good example. The result could have been that a reform in the field of kinesiotherapy was necessary and that that reform would generate resources, but the way the whole process went is a bad example.

I would like to interrupt Mr. Goutry for a moment.

Mr. Goutry, I understand, of course, that you have criticism of the way you work, but how would you have done it? Whatever reform is carried out, if it is accompanied by a certain financial submission, one always gets criticism. Now don’t think that the procedure that the minister will introduce regarding individual responsibility will not be criticized. When the numbers will come on the table and when one is going to see what one will have to deliver, there will also be criticism. So I honestly think your argument is quite weak.

You must admit that there were a lot of abuses in the sector. You also know there are too many Chinese. In the long run, the mentality is with the patients: it costs us nothing, continue the treatment but continue. These are often chronic patients who do not have much social interaction. The Chinese will soon become a member of the family. I have seen this happen to my own mother. It was not about kinesiotherapy, but about the nurse who came. In the long run, those people are more familiar with paramedical caregivers than with their own family. Therefore, the patients will never say that they no longer need those care, especially when it costs nothing.

I think the minister at least had the courage to take certain measures and cut off certain abuses. I can assume that the industry replicates that. The minister left an opening. He has said, “Tell me where you think I’ve gone too far, put forward your arguments, and then we rank those cases in another category for which more concern can be paid. But your criticism is too easy, I think.

Mr. Valkeniers, I do not make it easy for me, on the contrary. I realize that this is a difficult matter. I realize that it is easier to ask for more resources than to responsabilise people. I don’t even know what the best way is to do this. I know that pre-imposing a control goal cuts deeply into the sheet of the professional group — 10% is nothing — and then still at such a rapid pace. I do not think this is susceptible to repetition. Mr. Minister, you will also have to admit that if you did this with another professional group that was even stronger, the protests and strikes would have had more effect and this would have been much more difficult. I do not blame you for that. I have only said that it is not a good example of how certain things should be controlled.

The [...]

Mr. Valkeniers, if I find that there are abuses...

Frank Vandenbroucke: Mr. Speaker, at this stage of the discussion, I would like to thank Mr. Goutry for some positive comments and Mr. Valkeniers for his support for the policy. I do not want to get involved in the debate. I just want to make a communication that may be useful because several people who are present here have questioned me about this. Yesterday I had important contacts with the representatives of the two representative organizations of kinesiotherapy. We held extensive discussions yesterday. We made a number of very practical arrangements. In my commitment, I show that I will also, in the practical implementation of the reform, quickly make some adjustments with regard to the administrative questions that we now ask the kinesiotherapists and doctors.

We will also, in consultation with the kinesiotherapists and the medical associations, take measures to make a number of new administrative formalities as simple as possible and, in comparison with the original reform proposal, slightly lighten.

Yesterday I also confirmed to the Chineseists that there is an opening to create a number of additional possibilities for the completion of the new inheritance list. The negotiations are actually running smoothly. The reform is difficult, but the atmosphere in which I am discussing today with the representatives of kinesiotherapy is very positive. They are critical of the reform. We are making a lot of adjustments. Yesterday we had a very important meeting. I do not make much publicity around it because the organizations of kinesiotherapy should explain it to their own members. I suppose they will do that too. I would only like to report that there are new developments on the current topic of discussion, including the important discussion of yesterday morning.

I would like to return to what Mr. Valkeniers said. I urge you to continue to discuss this in all tranquility and openness. It is much more difficult to set up a constructive discussion on the question of how to control this problem than to constantly drum each other in the corner. That is not what I want. I am not saying I have the solution.

It is actually the method I have always accused of. Unlike other colleagues, I have not so far fundamentally attacked the minister about the dossier of kinesiotherapy. I have always said that I do not support the method. I don’t know if my method is better. I can only know it after it has been applied.

Specialists have also identified abuses. I mean double research, unnecessary research and waste. Suppose that one would tell the specialists or general doctors that one would cut the budget by 10% and that they themselves should find out in the course of a few months how they will deal with each other, how they will reform the nomenclature, how the fees will be arranged. How can one tell the specialists in advance that one decreases 10% and that one then begins to reform until one has reached that 10%?

Now you have provoked him.

Mr. Goutry, I give an example from the practice, which I left 8 years ago. I give an example. As a neurologist, you are called in an accident. Often I had to drive to the hospital at night for an emergency. An electroencephalographic examination was carried out. Well, for code number 5609K20 we were no longer reimbursed, because an electroencephalographic examination had taken place, of which I had to hand over half to the hospital myself. In the end, I worked for free. This was an important part of the budget. I admit that there have been repeated and in all specialties interventions. You also know that there is a budget. This did not happen under Minister Vandenbroucke, but among your ministers.

Mr. Valkeniers, I really do not intend to start a polemic on this, unless you really insist on it. On the contrary, I make a call in response to the bill to discuss how we can solve this in the future. I hear that the forecasted figures of exceeding the budget are more favourable than last year. That is absolutely your merit, Mr. Minister. We have no difficulty acknowledging this. I just call for a balance. Mr. Valkeniers, that discussion will be difficult. None of us has so far found the solution to the paradox. The paradox consists in the fact that it is necessary to be able to quickly determine that budget surpluses have occurred and that measures need to be taken, but that at the same time it is necessary to ensure that the measures are balanced, correct and responsibilising, and therefore not linear. The measures should punish those who cause the problem.

I have a little feeling that the minister has some tendency to keep the free initiative more or less in control. This tendency is probably in his genes; it is also inherent in his party and ideology and is supported by the green ideology. I have the impression that the minister wants to direct this from his own position and rather arbitrarily wants to decide how far the playing space reaches. The question is whether with this attitude one can carry out the best measures. I can give you a flower reading of the suffering experienced by patients through the reform of kinesiotherapy. As far as the professional group itself is concerned, one can speak of corporatism. Everyone protects themselves. However, if patients have complaints about this, there is a problem. For patients with, for example, a rheumatoid condition for which kinesiotherapy is very beneficial, the CRP standard for determining the degree of inflammation to be determined in the blood is increased to 3. Rheumatic patients who benefit from kinesiotherapy which reduces their degree of inflammation are punished by this. In the last few days, I have received a lot of fax messages about this. If you no longer get to CPR 3, you no longer enjoy the favourable refund rate.

Mr. Goutry, this is a matter that has nothing to do with the reform in kinesiotherapy. The problem you have cited is related to a specific test that one must meet in order to be included in the list of serious pathology as a rheumatic patient. This test is indeed completely meaningless and, for reasons incomprehensible to me, was included in a decision of the College of Physicians-Directors, which is the sole competent authority in this regard. This has nothing to do with the reforms in kinesiotherapy. Senator Remans, among others, has already complained about this in the Senate. I also hear from people in the field that this is incomprehensible to them. However, the College of Doctors-Directors tells me that at the time I had asked the Chairman of the Association for Rheumatology for advice on this. However, this is all history. In the meantime, I have informed the College of Doctors-Directors that this criterion needs to be changed and I will implement a modified criterion as soon as possible. I repeat, therefore, this has nothing to do with the reform in kinesiotherapy, but the criticism of it is completely right. This has already been stated by other members of parliament. We will adjust this and you may inform the patients concerned.

Thank you for your reply, which brings some clarification. We are overwhelmed with questions and problems and it is not always easy to figure out exactly where the problem is situated. This requires a debate.

I would like to conclude this general point by saying that I will remain very vigilant not to evolve into a situation where the activities of freelancers, including in healthcare, would be degraded. I would regret this, given the free professions...

(...) that there should be a limitation of the number of healthcare providers. To date, there has been only one minister who had the courage to bind the cat to ring, namely the current House Chairman.

The [...]

That is not true. Mr. De Croo then proposed to reduce the number of schools for kinesiotherapists. After him, the Catholic column established two additional schools. Apologize to me.

Mr. Valkeniers, allow me to finish my argument, otherwise we will constantly fall on side tracks, which does not benefit the clarity of the debate.

Anyway, it is a serious challenge to find a good balance. On the one hand, we need to better manage spending with more and more fixed budgets. This ⁇ increases the pressure on those involved, because they are treated as servants, while they themselves work as self-employed people who primarily respond to the needs. Again, I understand that something is being sent. In any case, it will be very difficult to safeguard the free initiative and at the same time to strengthen control.

I will come to the problem of the general doctors, because Mr Vande Walle, who had already talked about this during the discussion, is not present here. We have discussed all relevant articles thoroughly one by one and we support the underlying vision. It is obvious that family doctors will be included as full-fledged partners in the first line. The profession of doctor is supported. Encouraging the networking of general practitioners with other primary health care partners instead of single-person practices is a good evolution. Also there is the challenge to realize that within the context of the free profession and the free initiative. After all, it is very important that the competition ⁇ continues to play for medicine. I am talking about competition in terms of quality. In addition, the patient’s free choice must remain free. This is impossible if one has to resort to structures in which the patient has no free choice. In our country there is still that free choice, unlike other countries, and that we must continue to defend. This is also within the framework of the free initiative and in the structure of the free profession. Despite all the restrictions to be imposed, we will have to ensure that a proper balance is established. In countries with more directing or planned work where healthcare providers do not belong to the free profession, where there is no real freedom of choice and where there is actually no competition, there are waiting lists. In addition, the quality of health care is not the same as here. That is a constant, because the important motive, namely the motivation to be better and to be able to boast of a great practice with many patients, disappears. And it is precisely thanks to this latter — an extensive practice — that general physicians gain experience, which leads them to raise the bar for themselves, to acquire even more knowledge and simply to be better. If one touches it, then, of course, one gets a different picture.

The measures relating to hospitals constitute the majority of the draft. In the speech, I would like to pay attention to two important points. First, there is the structural underfinancing of hospitals. Whatever measures we take and whatever we do for the hospitals in the bill, there is, of course, the following constant.

Mr. Goutry, the underfinancing of hospitals remains indeed a very delicate problem. I have already asked the Minister whether it is not possible to engage in a dialogue on this in the committee with the relevant sectors such as the VVI and the public hospitals to find out whether that is correct and how much the amount is. It is, of course, unhealthy if a sector continuously lagging behind – according to the stakeholders it is about 17 billion – stays still.

Mr. Minister, I think you agree that we should discuss this.

Mr. Speaker, I find it easier for people’s memory that I interrupt when certain comments are made instead of saving everything. If you are interested in the room, I can say the following.

At the Ministry there is a working group headed by Mr. Tasiaux that examines this issue. Mr Valkeniers, we may, in October, on the basis of the report of that working group, eventually organize a hearing in the Social Affairs Committee or eventually together with the Public Health Committee. It will be possible to discuss certain elements. I can agree if this debate is organised in the presence of the public hospitals and the private sector hospitals.

Who would not support such a proposal? Mr. Valkeniers, we organized quite a lot of hearings in September last year in the way of introducing the Health Act. It was about the reform of the hospital funding. We then listened to the representatives of the hospitals. I do not know if we should hold hearings again to find out that the hospitals are on their gums and that they have to deal with structural underfinancing for certain services. I think of the emergency services for which additional savings are imposed. I can understand that their hair has been lifted to the mountain if the draft asks a delegation to ask for a flat-rate contribution to the patient who uses the emergencies.

Hospitals want to address the problem thoroughly. They do not want to opt for asking for all kinds of supplements because this creates a threshold even if one recovers it and even if one works with social categories. However, the principle is unfavourable because in this way one can always switch to asking for supplements if there is a suspicion of improper use in certain situations. A supplement request for the emergency service may pave the way for supplements for other services. There are still many services in a hospital that are consulted without the patient first going to the general doctor, which are consulted too quickly which then leads to waste and improper use. Nothing is done on this level and that is the cause of the dissatisfaction in the hospitals. Hospitals want to be listened to the real problems of underfinancing.

I remember a summer ago a snorkel predicted that the social security budget would show a surplus. In the full holiday period, there were several of our colleagues who made suggestions to spend the amount in a certain way. We then pledged to use this surplus to adjust the underfinancing. This is exactly a year ago. In the meantime, hearings have already taken place. Mr. Valkeniers, nothing has happened to this point so far. Their

However, there is an additional problem. I do not want to get rid of it easily by highlighting the problem of new funding in hospitals and pointing out the chaos that this has brought. Such a method seems to me too cheap. During the discussions of the relevant bill in January, we have already pointed out the difficulty of implementation in hospitals. You said then that you would try to make the measure effective by 1 July. It adorns you that your action force drives you to make decisions.

You may not have heard it yet, though I doubt it, but at this time it is all going very hard in the hospitals. It is almost dramatic. More than a hundred pages of technical guidelines were received a couple of weeks ago. All this needs to be worked out now, while we are still working with the current financing technique. However, we should already start with the new financing technique. We have given ourselves some delay for, for example, the recovery of the financing of the pathology and this until 2003, because you yourself thought it would probably not be feasible. What is currently being introduced in the hospitals with all the associated body load seems to be really alarming. I say this also at the request of Mr Vandeurzen, here absent, but closely involved in the operation of hospitals. He describes the situation as very alarming and that in all hospitals. One sits with hands in the hair and does not see how one will succeed in integrating the whole, complex new financing in the short term and being able to work out this already. I urge you to pay attention to this, Mr. Minister, to remain alert and to remain in as close contact as possible with the sector. It is not about someone’s right, but about recognizing the problems and looking for solutions. This makes it possible for hospital managers to handle their affairs in order. Their

The bill contains the important article 11 on the financing of pathology. We stand behind that. It is a good thing that in the long run one can introduce an equal price for equal treatment. We also support that one has a clear view of what one treats, how much it costs, for what kind of patients, what the golden standards and guidelines that should be used. We fully support this. This concept for hospitals is focused on the future, but then on the condition that also the free initiative and the competition must continue to play and that the quality stimulus can remain there too. We have some concerns about a model of recovery where a hospital administrator will have to see after date if the famous 10% margin has been exceeded, how that can be recovered. The administrator will, of course, face a difficult problem and will have to involve his doctors. I remember Mr. Mayeur’s question about what to do with doctors who are no longer employed. He also pointed out that it will be more difficult to reimburse non-contractual doctors with self-employed status than doctors who are contractually linked to a hospital. Mr. Mayeur belongs to the majority and has discussed this in detail in the committee. This was not from the opposition, but was meant to warn you. This was to make it clear that this recovery technique is not so easy, that everyone must be able to do their work in a flawed way, and that it must be ensured that recovery can happen seriously.

Another point is the famous financial commission in the hospitals. Of course important, Mr. Valkeniers, is that administrators and doctors can cooperate with each other in all transparency and also on the financial level. There are mutual rights and duties. If doctors require more involvement in the management of hospitals, if they want to see what is happening — they have the right to do so and can do so today — if they want to investigate decisions, look at investments and share costs, then it seems to me that one must also accept the consequences of it. I mean the consequences of co-management. Therefore, responsibility must be taken.

Mr. Speaker, Mr. Goutry, I would like you to reconsider the situation in the past. The famous Hospital Act was finally enacted by a royal decree by our former Prime Minister Jean-Luc Dehaene. Then in the Senate — I was then a senator — was spoken of a consultation model. This would be an example of a consultation model. Even my colleague and group leader — late Dr. Vandekerckhove — was caught up by this model of consultation at the time. I then predicted that it was not a consultation model, but the beginning of a crisis or war model. This has also been shown in virtually all hospitals because one always wants to take more and more charge of the honorary remuneration of the doctors. You know that too, Mr. Goutry. You have then spoken about submissions imposed by Mr Vandenbroucke, but I have not yet heard you say anything about submissions by the administrators. The administrators in some cases make a greater attack on the honorary remuneration than the minister himself.

The big problem was that ultimately no expenses were allowed to be made for which the doctors were subsequently required to contribute, unless they were informed and informed and expressed their consent, but in most cases they were not informed. They didn’t know what it was about and just had to pay the bill. When I asked the minister whether they could be assisted by an accountant — doctors are ultimately not accountants — I was answered that there was an accountant. I asked the hospital’s accountant if he wanted to assist the doctors, but he pointed out to me that this was not his job. Its task is to verify whether the accounting is carried out in accordance with the legislation. He is not an accountant, but an accountant. Until now, doctors have never had the opportunity to be assisted by someone who is informed. In very many cases, they were also not consulted for the expenses incurred. I think this is the beginning of an improvement in the situation.

Mr. Valkeniers, I will not comment on this. I’ve listened to your words and I see that the minister is doing it. I leave your words for your own account.

I’m just asking whether the financial commission d’office will provide a solution to the problem you’re pushing forward. I support that financial committee, but you give the impression that this will solve the problems. On the contrary, the problems may be much greater.

Mr. Speaker, I will once again give an advance reduction on a final replica that I may not even need anymore.

Mr. Goutry, we had the following strategy in mind. Knowing that we are here with a fundamental tension in the system, we must first ensure transparency. Facts must be on the table at all levels. The famous Tasiaux Working Group, which examines the questionable 17 billion, will put the facts on the table on the problem of underfinancing. The doctors in the hospitals will now — whatever the way of collecting the fees — get the facts on the table because of the administrators about the financial flows in the hospital. They will be able to assist in this. If one wants to bring solutions to a difficult situation – which is indeed full of tension and suspicion – one must have the facts on the table at all levels. We do that now. I think Mr Valkeniers is right. This design is an important step. I know that not all hospital managers are enthusiastic—to put it gently—but I think we should do this.

Mr. Minister, it annoys me — and I am neither a doctor nor a hospital administrator — that in such debates there is always an elected party. Either the doctors are the victim, or the administrators do not give access to the accounting. It is not about that, right? Just as there are good managers and good doctors, so there are people who do it in a different way. In my opinion, this is not the subject of the debate. These are the tools made available to conduct consultations with full knowledge of the matter in the best possible way. I add that this should be done with shared responsibility. This applies to both the one and the other party, Mr. Valkeniers. I have nothing against the doctors and nothing against the administrators. I want to ensure sound and rational management without waste. This is the task of people who want to take responsibility in politics and in the field of policy. In addition, doctors should also register in a context where they are not just going to lay their eggs in the hospital. I mean by this that they should not leave all the burdens to the hospital and attract all the lusts in their practice at home. This situation occurs and can sometimes damage the administrators. Let us in this call for a very constructive discussion. It will not be easier, Mr. Valkeniers. It is not because there is a financial commission, because there are corporate auditors and financial experts, because suddenly all the figures and all the books will be laid on the table, that it will be easier to come to a ventilation of the costs. Maybe the opposite. Regarding the urgent cases, I would like to return to the comments already made in the committee. If the emergency supplements come and they are also incorporated into the maximum invoice — as this is partly the case for kinesiotherapy and ⁇ also for other things such as the list of viscerosynthesis products — then we must ensure that the system of the maximum invoice is timely supplied with the necessary oxygen. We must ensure that the budget is large enough. There was a certain envelope. The Minister made statements on this when dealing with the draft law on the maximum invoice. In response to our comments, the Minister then replied that it is not possible to arrange everything endlessly. Their

We have one week left for the summer vacation. There will be no time to ask questions in the committee. Mr. Minister, the idea has matured to include the kinesiotherapy in the maximum bill. I would like to draw attention to the vulnerable categories, the people who have more difficulty. An increase in the brake fee will be refunded through the MAF. This is done on a proportional basis. I have been given a technical explanation in this regard, in particular in connection with the reduction of the M-value. If one has to pay more brake money, that brake money is not simply refunded through the maximum invoice. Only a portion of that brake money is refunded, in particular the difference between the brake money that the patient now has to pay and the brake money that he would have paid in the previous system. I have received repeated reports from the industry about this in recent days. It may have already been discussed yesterday.

Mr. Speaker, today there is a royal decree for the implementation of the law on the maximum invoice which clarifies this. Indeed, I gave this information to the representatives of kinesiotherapy yesterday. The brake fee that a patient pays at a 19th session for a common pathology and thus actually falls into a situation where there is less refund is included in the maximum invoice insofar as this amount is not higher than the brake fee paid for the first 18 sessions.

One draws through what the patient paid as brake money in the first 18 sessions and that same amount he can recover in the maximum invoice. To the extent that his brake money is higher than what he paid in the first 18 sessions, he can’t recover it. Mutatis mutandis the same applies to patients who appear on the F-list: at the 61st session, the refund decreases in proportion to the first 60 sessions. The brake fee that they then pay is entirely included in the maximum invoice, insofar as it is not higher than the brake fee that was valid in the first 60 sessions. In my opinion, that is the most generous interpretation one can give. This, of course, is not a full coverage of the brake money to the extent that it becomes higher. By the way, that was not the intention.

I handed over a table of numbers and the full explanation to the kinesiotherapists yesterday. They can inform their patients about this. This is reflected today in a royal decree that, unless there is any political earthquake, will be approved in the Council of Ministers. I will also disseminate information on this.

Mr. Goutry, can I ask you to finish?

Mr. Speaker, I am almost finished. Mr. Minister, is it then that the persons with whom you spoke yesterday agreed to this interpretation? There was a lot of uncertainty, especially among the kinesiotherapists. Have they given their consent and said they support this arrangement?

For all clarity: if one applies the normal brake money for that type of treatment — which we advocate, since we have said that we are in favor of a mandatory collection of the brake money — then the brake money for the patient is much higher, as the refund reduces.

If I understand it correctly, then you now say that you can count that same faction, namely, what could be given to the french money for the MAF, can be transferred. Of course, the decalage will be greater, because the amount you have to pay will be higher. In my opinion, this is a misunderstanding, because the patients thought they were a privileged category, the vulnerable group. Their reasoning was: if we need the kinesiotherapy further, then we do not suffer any loss as we get the brake money back through the maximum invoice. This is of course not correct.

I have never said that either. The system has only become more favourable compared to the first statements I made about it.

Mr. Minister, I asked you this question once in the plenary session and you answered that the amounts would be proportionate.

Indeed, but now the repayment is better, than if it would be proportional. My first interpretation was: the brake money recovered in the MAF decreases in proportion to the brake money recovered in the MAF from the first 18 sessions. It drops, as the repayment drops. That was the meaning of the word “proportional”.

The arrangement I have now made with the RIZIV, which is recorded in a royal decree, is that the brake money recovered in the MAF will not fall; it remains identical to the brake money of the first 18 sessions. So that is more beneficial than what I initially explained, and even more beneficial than what I first wrote in letters to people. It is therefore ⁇ not worse, but on the contrary more beneficial, but, it is not my intention to make everything free, because I think — and you will agree with it — that such a thing makes no sense. That people have to pay a few euros at the 19th session or at the 20th session, or at the 61st or 62th session, even if the participants enjoy the maximum invoice, seems to me acceptable. After all, we assume that it is exceptional that, at least in a common pathology, more than 18 sessions are needed. It is not excluded, but it is rather exceptional.

I think this is a very fair arrangement. You know that matter very well and so it is not so difficult to explain it to you. However, it is not so easy to explain it to the kinesiotherapists and to the patients, but we will make sure they are very well documented. Yesterday, by the way, I gave a whole folder with documentation to the kinesiotherapists.

Mr. Goutry, this is, in my opinion, a good measure. If no brake money is introduced, the situation of the past will remain, in which kinesiotherapy was given until the end of the days. In the committee, you have defended the responsibility of the patient. The VLD is also in favor of this. The responsibility of the patient is necessary and this is the only way to responsibility. There are too many Chineseists, and they will come forever without the patient’s responsibility.

Mr. Goutry, I ask you to close your argument. You have already exceeded the permitted speaking time of 19 minutes. However, you were interrupted and I took that into account. The debate was interesting, but I would be pleased if you would end your discussion.

Mr. Chairman, Mr. Valkeniers, the CD&V group has never been against brake money. The opposite is true. Currently, the brake fund is already 25%, which is 130 billion Belgian francs. If the patients can pay an increased brake fee, we will not have much trouble with that. My group calls for attention to the limited category of people who may belong to the maximum invoice. Everyone agreed that this is the vulnerable group. Special precautions should be taken for this category. I’m not talking about the brake money in general, but about this specific group.

Regarding the emergency footage, I reiterate my urge for the alleged improper use of this service to be thoroughly and globally investigated. I know that the minister has asked to stop talking about "unfair use". However, the term has been launched and the debate will be carried out in part on this. It is necessary to investigate who is registering for the emergency services. If one wants to install systems of evacuation or drainage on the roof, one must first investigate who uses the emergency services. It is also necessary to examine the number of psychosocial problems that occur and to examine other urgent ways to organize a twenty-four-hour insured waiting service to address the psychosocial problems.

My group has no problem with a robust advisory body such as the multiparty. It is good that this is an organ with authority. However, it will have to work better than the current tripartite. The multiparty has possibilities. The powers become wider. There is a good chance that there can be better work in the future. The representation should be highly representative. Otherwise, it is not possible to organize a good consultation on hospitals. My group has upheld its amendment calling for all seats for all banks to keep the status quo and not to reduce so that representation is guaranteed. There are different types of hospitals, public and private hospitals, various federations and domes. Everyone should be able to do their work fully and be represented. I repeat that CD&V has no problem with a good advisory body provided that it operates sufficiently democratically and provides space for everyone.

My last point relates to the financing of the rest homes. A new step is being taken in the budget financing of rest homes. My group supports an amendment — it is almost symbolic — which states that, if one assumes a budget for rest homes and for rest and care homes, the budget must be realistic and cover the actual needs of care burdens for the elderly. This care burden will constantly become heavier. People later go to a resting house. The average age at the time of admission is 85 years. Usually these people need heavy care. We must absolutely ensure that these people can get all the care they need. That this is done with a budget funding, we feel because it increases responsibility. It also makes it a little easier to be able to avoid all possible rules, sometimes even the most insane. The rest houses know where they are. However, you will need to ensure that the package is large enough to fully guarantee the assistance that must be provided there.

These were the most important comments that I would like to repeat in the general discussion. We have submitted 13 amendments that will be discussed later. In the light of this general explanation, those amendments may later be limitedly motivated.

Mr. Goutry, I have let you speak for a long time. There was also a lot of debate, including with Mr. Valkeniers and the minister.

Mr. Speaker, Mr. Minister, dear colleagues, first of all, I rejoice at what this project does not contain and in particular that all measures relating to the individual responsibility of practitioners and the reform of the control service have been withdrawn. I welcome the act of wisdom that constitutes this withdrawal. In fact, it seems to me that these measures must be deeply renegotiated with the sectors in a spirit of dialogue and concertation, to allow the healthcare sector to benefit from a climate of positive concertation rather than fall into the organization of trunk wars. In this regard, I wanted to insist that all this sector of individual responsibility, which is indeed very important, can be renegotiated in a serene climate before being submitted to us.

Mr. Goutry, you have spoken for about fifty minutes.

I propose not to interrupt repeatedly. It is not about me. Of course, I could not know what Mr. Bacquelaine would say now, so I could not incorporate that into my presentation.

This is a double morality, which I mentioned earlier. Mr. Bacquelaine is a doctor. He says here that he is delighted with the fact that there will still be a thorough consultation before the budget of the doctors will be cut. This reduction should not be done in a hurry. With the same ease he agrees with the advance reduction on the budget of the kinesiotherapy, which he finds good that there is a subsequent consultation. That is the corporatism that celebrates high here, as I have always said. As a doctor, it goes well. Doctors are not yet able to save money. As long as the doctors are willing to save money, they will protest.

Mr. Bacquelaine, that is a bad mentality, with permission said, which you should actually avoid. This is not responsibility at all. What you say is corporatism. You choose your own shop. You can still accept savings in kinesiotherapy, but if the minister begins to cut in the list of doctors, it will be a little harder.

Mr. Speaker, I would like to confirm that I have started an in-depth negotiation on the project relating to the accountability of service providers. by Mr. Bacquelaine is right, not as a doctor but as a parliamentary. For a project aimed at sanctioning service providers who have obvious practices deviating from the standard, it is important that the methodology is coordinated with the field actors. This seems to me quite legitimate. I have had a lot of contacts and I am organising a deep consultation on this project.

I would like to make a somewhat technical comment in response to Mr. and Goutry. Part of this project does not only concern doctors. It is about providers, that is, not only doctors, but also other categories. This is an important point. We should not focus on doctors when talking about this project of accountability.

I would simply say to Mr. Goutry who seems to know my original profession...

Mr. Bacquelaine, I want to be very clear. I am pleased that some parliamentarians have a specific training and profession. This does not bother me at all. I do not want to hear criticism about the exercise of a profession or about the training of one or the other. This is an enrichment for Parliament, regardless of our education and profession.

I know I can’t ask Mr. President. Goutry from the top of this tribune.

Mr. Goutry, in order for us to play with equal weapons, we might ⁇ have a conversation recently during which you would inform me about your original training and your professional experience.

I would like to return to the proposal presented to us today. This project has two major important aspects, in my opinion: on the one hand, the measures aimed at the general physician and the practice of this first-line medicine in our country; on the other hand, everything related to hospital policy.

Before addressing these two topics, you will allow me to return a moment to the reform of the kinesiotherapy. I know that this problem is not the subject of the current project but Mr. Goutry spoke long about it and several session interruptions were devoted to this subject. I look forward to making further changes to this reform. That is, the reformist spirit, let the chairman of the reformist group recall it, the spirit of a reform is obviously a dynamic of change. To print a true dynamic of change, it is necessary to accept that a reform can be continually brought back on the business, in order to improve and adapt regularly what is done. This need for reform seems to me obvious, especially on three points: - the administrative complexity that a profession can encounter; - the composition of the famous list F which is the subject of a series of important discussions; the adaptation of this list must be a reality; one cannot once and for all consider that this list is fixed for eternity, it would have no sense in relation to the evolution of medical practices that must be subject to permanent adjustments; - the notion of ticket moderator; I address it because, in my opinion, this concerns the whole of health care services.

If we introduced moderator tickets, it was precisely because we wanted to moderate consumption and empower the patient. This is part of a policy of accountability of the latter. Moderators should be noticed. This perception should also be better organized, especially since we now have a system of the maximum to be charged that allows to avoid the harmful effects of the moderator ticket on a social level and in relation to the most impoverished patients. And from the moment that one has such a system, it is all the more normal that moderator tickets are subject to better perception control.

These are the few comments I wanted to make on this subject. I will now address the two main themes of this bill.

The first concerns the hospital policy. I will be relatively brief on this subject. by

Therefore, reference amounts are introduced for a series of health benefits that are provided under standard procedures. This new concept is useful for removing practical differences that can be found in standard procedures applied in our country’s hospitals. by

This measure is, in my opinion, a first tool for controlling hospital costs. It should be noted that these costs are obviously the main source of insurance expenses. Therefore, it is good to have effective tools in terms of cost control.

The available data should bring clarity, transparency or level of the specific situation of each hospital and should allow comparison in terms of activities with the average of the hospitals in our country.

It will, of course, be appropriate that the measures aim to raise awareness, to awaken a behavior that is more based on "medical evidence base".

However, a trial period should be established to raise awareness among hospitals that deviate from the benchmark and to analyze the causes of the deviations rather than immediately sanctioning any deviation from the standards or reference amounts. I would also like to point out a significant achievement of our work in commission. An amendment has been introduced. It introduces the notion of shared responsibility between hospital managers and hospital doctors in accordance with the regulations referred to in the Hospital Act. This is an important clarification for us. These relationships between hospital managers and hospital doctors are an essential element in order to organize a better control of hospital costs without neither of them having the feeling of being the victims of a position that might appear to them as partisan. by

I hope that the Dillemans Committee will soon conclude its work and that the government will be able, very soon, to make a decision on the necessary clarification of the relations between hospital doctors and hospital managers, in particular within the framework of the famous article 140 of the law on hospitals that must be amended.

Regarding the aspect relating to general medicine and the measures that are established in order to modify certain elements and revaluate general medicine, I would like to say from the outset that there is at present, among general physicians, a dismotivation. Do not see corporate interest in it, Mr. Goutry, since I no longer practice general medicine on a full-time basis, even though I remain ⁇ attached to it.

This dismotivation is ⁇ due to a low-value level of remuneration, a precarious social status — like the self-employed in general —, increasingly demanding working conditions, uncertainty in the workplace but also uncertainty about the future of this profession, which is the main issue. by

The evolution of general medicine imposes on general practitioners an ever-increasing and increasingly time-consuming permanent training. If one adds to this the administrative obligations facing general physicians, which become inherently unreasonable, one can imagine the state of mind that prevails within this profession. All these administrative training obligations hypothesize the time spent by the doctor on patients — which should obviously remain the primary goal — as well as on his family life. The time spent listening and examining the patient remains, in my opinion, markedly undervalued and undervalued. by

In any case, the general physician must remain the pivot of the organization of outpatient care and it is important to give him the means to do so. by

The present project introduces four measures that I find interesting and tend to solve, in part only, the problems encountered in general medicine. by

The first measure is to introduce a bonus for doctors who meet certain criteria for good medical practice. This bonus would therefore be partly integrated into the accreditation system. These provisions must, however, be taken with a certain circumspection. As I said in the committee, one must obviously be careful not to create a system that puts in opposition the medical doctor’s own financial interest and the patient’s interest. As I said to the Minister who was willing to give me some calming elements on this subject, one cannot compete the interest of the doctor and the patient in terms of quality of care. Quantitative criteria should not interfere with qualitative criteria. In this regard, the quality of care should remain of primary importance. by

This benefit should not be limited to general practitioners. It should also apply to specialized doctors. It will be up to the Medicomutualist Commission to take concrete measures within the framework of this bonification, which must be applicable, not only to general physicians, but also to specialized physicians.

The second measure concerns the establishment of a availability fee for guards. My group is pleased with this measure, which is an old claim. It is highly desirable and deserved. I would like to remind you that the general medical guard is actually the equivalent of a real public service. It is normal that the public sector participates in the proper organization of these general medical guards. The dissatisfaction of general physicians with regard to the guards is a serious problem. It emphasizes the need to take effective measures in this regard. The mobilization of practitioners for long hours is incompatible with privacy. As a result, many general practitioners no longer wish to participate in the care roles that are less and less "profitable" in terms of the organization of the profession. This fee of availability seems to me to be necessary.

This availability fee will revive the motivation of doctors to accept custody. He recognizes the value of the availability of the general physician. It will therefore ⁇ encourage the return of general doctors to the outpatient care services. This element will allow to limit the direct recourse to hospital guards, which is a real problem in terms of optimum use of the financial resources available within the framework of health-invalidity insurance. by

The affluence to hospital emergencies is not only explained by problems with the availability of outpatient guards. This problem is also explained by the search for freedom and ease by some patients.

Therefore, the fee that will be requested, under certain conditions, in hospital emergency services is an appropriate element, provided, of course, that it does not mortgage the quality of reception at the level of emergency services and that it does not endanger the most disadvantaged patients. In this regard, measures have been taken to make corrections in this matter.

Regarding the guards and the possibility for the general physician to practice the third-party paying during the guards, it seems to me that this measure will be truly effective only on the day when the problem of returning the certificates of care to the mutual organs has been resolved. At present, general physicians must, the day after a guard, and if they have practiced the paying third party, devote some time to send back the certificates of care to each of the headquarters of mutual and mutual organizations, while a centralization of the return of these certificates would allow to ease this administrative task, which ⁇ discourages a certain number of physicians from engaging in this practice.

A third interesting measure, in my opinion, is a financial intervention for the use of telematics and for the electronic management of medical records. This is an inevitable breakthrough in the practice of modern medicine. Hopefully, this generalization will lead to a significant reduction in the administrative work of doctors. by

In the same spirit, the introduction of an honorary to general physicians for the management of the overall medical record and the revaluation of this honorary is an interesting element. It merely concretizes, through a legal basis, an existing structure and measure. However, it is necessary to revaluate this fee regarding the overall medical record to give it a better development as part of the practice of front-line medicine. Furthermore, information about the patient should be improved. Indeed, I am surprised to see the large number of patients who still ignore the possibility of registering as part of a comprehensive medical record, while this measure has already existed for a number of years now. Nevertheless, information efforts in this area need to be further strengthened.

As positive as all these measures may be, the priority in terms of revaluation of general medicine still seems to me not widely met. The revalorization of the intellectual act is probably still necessary. We know that French generalists have recently obtained a very significant revaluation of the fees for home visits and consultations, raising these to 30 euros and 20 euros, respectively. It seems to me that this revaluation exists in most European countries and that Belgium remains behind, even though advances in terms of availability fees and overall medical record fees are useful and desirable. However, the revaluation of the intellectual act must still benefit from constructive measures. by

I am well aware that it is obviously not possible to revaluate immediately, and at once, the intellectual acts in general medicine, as well as in specialized medicine. But I think we have everything to win. Indeed, the revaluation of the intellectual act, on the one hand, will strengthen the quality of medicine and, on the other hand, will allow to limit the abuse of certain acts of technical medicine, which are sometimes made necessary only in relation to the insufficient means available to the practice of intellectual acts. by

I truly believe that financially, health insurance would have an advantage in orienting itself towards a greater revaluation of the intellectual act. That is why I call on the government to effectively program this revaluation in the near future and to give a very important signal to doctors in terms of revaluation of the intellectual act, which would lead to a removal of the profession while indicating the government’s willingness to orient itself towards a better quality of medicine.

Colleagues, the Committee on Public Health, Environment and Social Renewal will meet at 12.30 for the discussion of some amendments, namely those of Mrs. Pieters, Mrs. Descheemaeker, Mrs. Gilkinet, Mr. Hondermarcq, Mrs. De Meyer, Mr. Bultinck and Mr. D'haeseleer.

Mrs Avontroodt, I would like you to come and give a verbal report on the decision of the committee so that we can finish our agenda this afternoon.

Mr. Speaker, Mr. Minister, Mrs. Minister, colleagues, every individual has the right to adequate health care according to the Constitution. However, these health benefits have a price. As a result of the ageing population, technological advances and the higher demands of the consumer – the patient – those costs are rising very rapidly and it is becoming increasingly difficult to keep health care accessible to all within the budget provided. In the present bill there are a number of positive incentives to resolve some pain points that I would like to briefly explain.

It is essential that the right care is provided in the right place. We therefore welcome every step towards the revaluation of primary care, where the primary physician is the central figure. We welcome the recognition of general medical circles, the legal regulation of the fees of the global medical dossier and the introduction of a availability fee for general physicians providing an organized waiting service. That new fee should provide a partial solution to the sometimes misused use of emergency services. After all, when there is no general doctor available for problems, patients turn to the emergency services without medical urgency.

Also in the agreements between doctors and hospital funds, the family doctors are appreciated more. In decisions that are specifically concerned with them, the majority must consist of at least half general practitioners.

For the financing of hospitals, the principle of reference amounts is introduced as a means of updating a number of matters. The national average cost price — increased by 10 % — of the standard operations for a selected group of pathologies will be made known via the Ministry’s website. If hospitals exceed that reference amount by 10% for more than half of their pathology groups, that amount will be recovered.

We can ⁇ support such a measure. However, there is a margin of 20% in exceeding the national average and this in more than half of the pathology groups before sanctioning. Isn’t that a little spacious? Similarly positive is the entry into the GVU law of dieticians and podologists for specific concerns in diabetics. 1,600 amputations are performed annually, many of which can be avoided if better prevented.

I would also like to make a negative comment. Given the evolution in the ROB and RVT institutions, where an increasing number of heavily caring elderly persons are being accommodated, this sector remains underfunded. The Government must take due account of this in the upcoming budget discussion and increase the resources for the real costs of care based on the degree of dependence on care.

If the policy is rightly intended to maintain our sound health care system, its costs must be controlled without compromising quality and accessibility. This requires awareness and responsibility of both the caregiver and the caregiver. The doctor and the patient should be aware of the cost of health care. This draft legislation sets the first but cautious steps for this.

Agalev and Ecolo will support this design, but wish to look even further in the future. Last year, for example, in Flanders, in the annual selective collection of 316.258 kilograms or more than 300 tons of old and decayed medicines at Ovam. This number applies only to Flanders. Especially with regard to drug consumption, concrete steps will therefore need to be taken.

Any reform that affects financially one or another group will never be welcomed by that group. However, in order to conduct a good policy, one must have the courage to assist in consultation and with knowledge where it is needed.

Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker. I would just like to make a few clarifications about the positions we want to defend.

One of the important points concerns the revaluation of the role of general medicine which implies, for our group, a certain reorientation of the financial flows towards the first-line care, the strengthening of these structures as well as a new delimitation of the “power” between the different lines of care. This cannot under any circumstances mean the dismantling of hospital networks or the artificial limitation of useful resources to specialized medicine and medical technologies. It is obviously not about making medicines at a discount but complementary medicine, with good complementarity in the interest of the patient.

The chapter dedicated to general medicine, concretization of some initiatives inspired by the report of Dr. Vandemeulebroeck, thus meets our concerns overall.

There are also a number of new remunerations for general practitioners: bonuses for those who meet qualitative and quantitative criteria of medical practice, availability fees for guards, intervention for the use of telematics and for the electronic management of medical records. However, it should be noted that the final quality of the expected changes will depend not only on allocated budgets but also on the degree of mobilization on the ground. For us, this latter aspect is primary. There is a need for membership, including general doctors, to all these devices to make them work.

The establishment of the general medical record can also be qualified as a success in terms of its quantitative development. Its strengthening — notably the expansion to the entire population, a better remuneration, a reduced moderator ticket with the doctor who holds the dossier — is, in our sense, the way to prioritize as a priority not in an objective of rationalization, which is by no means corroborated at the current stage of evaluations, but in order to ensure the continuity of care and the central role of the generalist. The general medical record must be the preferred instrument of communication and collaboration between the different levels.

The establishment of a legal framework for granting bonuses to physicians who meet qualitative and quantitative criteria of medical practice will, in my opinion, require detailed explanations on the ground. by

I believe that information on this subject should be the broadest. Contrary to what was envisaged in the statement of reasons, the text of the original Article 3 did not provide that the National Council for the Promotion of Quality would be the competent body to fix the parameters. The Committee and the Minister accepted an amendment on this subject and I thank them.

Availability fees are important for guards and are directly related to the problem of using hospital emergency services. I will address these two issues together.

The exposition of reasons suggests a regulation that addresses the problem globally: care services in general medicine, emergency services in hospitals, patient and physician accountability. We need to join in this global path. If one finds on the ground that an increasing part of the activities of emergency services in hospitals are dispensary activities — a one-off experience in a hospital in Brussels has shown that indeed a majority of emergency consultations belonged to general medicine — one cannot say, despite these sporadic analyses, that there is to date a serious study that can accurately quantify the problem and its multiple origins.

In a committee, the minister took the example of England and compared it. The conclusion is that this is a European phenomenon. That being said, this does not allow us to analyze the English model with the situation in England to lay it on the Belgian situation. A simple example: waiting rows exist in England while they do not yet exist in Belgium. This is ⁇ one of the parameters that do not exist in our country, but which could explain such a recourse to emergencies in England.

There are several parameters. It may also be necessary to include the fact that precarious patients generally do not have an alternative to a comparable price. When they exist, precarious patients do not necessarily know about their existence or are poorly informed about the cultural habit of consuming hospital emergencies. It is therefore an important parameter in large cities that should be integrated into our analysis.

Without an accompanying measure, the flat-rate contribution, which can be considered for so-called unjustified or abusive appeals, will undoubtedly penalize the most disadvantaged populations, those who, precisely, are the most culturally and socially detached from the wise use of the different levels of medicine.

There too, and I thank the commission and the minister, the amendment I had submitted to include in the maximum invoice the possible cost that would be borne by the patient during an emergency consultation, is an important social correction. by

This social correction is important. It is also not negligible that the commission and the government have accepted this amendment, because this social correction comes to compensate for the fact that people are resorting to emergencies for social reasons. by

This bill clearly states that no contribution can be requested from patients for the use of emergency care. And those who do this today, such as the VVI, will have to keep this in mind. The Minister’s response was clear. This was already the case at the end of the questions raised in the plenary session on this subject. It is important that this could be recalled in the committee, especially in view of the provisions that we have taken in this bill.

Mr. Speaker, of course, everyone is of the opinion that a strict regulation of the supplements on the emergency services is necessary. We even find these supplements unnecessary because — and that you should add when you talk about the VVI — the VVI has actually sounded another alarm signal, in particular that there has been a structural underfinancing of hospitals for months, ⁇ even years. Recently, several austerity measures have been taken, among other things, on emergency services. That was the signal from the VVI and not the static story about a maximum of supplements.

Mr. Speaker, I know the argument and I agree, like others but like everyone can be, including the government. We are suffering from a structural underfinancing of medical practice. We need to think about how to get better funding for this sector. The bad signal given by the VVI is to propose that it is the patient who compensates for this structural underfinancing that everyone recognizes and that involves a restructuring of the entire healthcare sector. I repeat, it is a very bad political signal to weigh this structural financing deficit on patients. I think it is very happy that the government and the majority are not moving in this direction. The VVI is making a political mistake and that is regrettable.

I am, on the other hand, very happy that the majority and the government have decided to think about a restructuring of the whole of this sector, to make the general physicians participate in the roles of custody, with fees paid, to restructure this area, not to make the burden weigh on the patient and if a contribution is decided, to add a social correction by allowing the poorest to introduce this cost in the maximum invoice. I think this is a completely different approach than the political signal given by the VVI asking for 25 euros per patient. You might have thought twice before making such a proposal.

I would like to return to the problem of emergencies and especially decided savings, namely 320 million in B1 and B2 for unjustified and emergency-induced appeals. by Mr. The Minister replied that there is no scientific analysis of the abuse of emergency services, although there are a number of parameters available. I asked the Minister of Health, Ms. Aelvoet, if we had a map of alternative guards outside the hospital. We also do not have this element. I am not blaming the government; there are probably all sorts of explanations for this gap. by

However, it must be acknowledged that it is boring to make savings in this sector, savings based on improper use of emergencies, when one does not have the ability to scientifically justify the reality of these improper uses. There is an undue use, and we know it, related to the social situation. Some believe that emergency treatment is free, while at the polyclinic or consultation, they have to pay. This is obviously one of the major problems. There is also, it is true, the consumption of emergencies by the stressed framework that does not want to go in line and prefers to go to get treated quickly and urgently in hospitals.

This is unacceptable, of course, but it is a social phenomenon. As you eat fast — a “wasted food” by the way, but finally, you eat it fast — some people think that healing quickly is part of a lifestyle that they must integrate. I think this is not a good thing and it should be punished, but we should not punish the whole system. I am also interested in the fact that the Minister responded in committee that it was indeed necessary to think about the whole problem. by

Finally, I would like to intervene on the issue of reference amounts that should, according to the explanation of reasons, according to the bill, mitigate the differences in practice in hospitals. This will allow, still according to the project, to abandon the linear recovery system that is applied today and where performance indicators are not taken into account. If we understand the mechanism put in place here, the gap of more than ten percent — and we have received the tables with the equation proposed by the government — will be counted on the fees taken into account to the insurance. Obviously, this device can be subscribed as long as it does not result in selectivity both at the level of pathologies and at the level of patients. That would of course be unacceptable. by

The question that arises for us, I asked it in commission and I repeat it here, bringing my answer. What will happen when doctors are statutory or employees? The solution is currently impractical in hospitals. I will give an element of answer. It would be sufficient to accept in the Hospital Law the existence of public hospitals or academic hospitals that employ wage personnel, whether it be recognized as such. I think that it will then be possible to have a differentiated treatment between private hospitals and public hospitals or employees because the relationship between the manager and the doctor can not, of course, be the same. Of course, the relationship is different.

Finally, the technique of skyscrapers that will be published on the website is obviously stigmatizing for the hospital concerned. If it is a bad practice, it must be denounced. I think it is important that the hospitals concerned have the opportunity to express their views. A clarification on this subject has been made to the project. The reference must also be published on the site, otherwise we would not understand what it is when we want to make comparisons. by

I conclude with two points. We support, of course, the principle of creating a financial commission within each hospital. I think that in the relationship between managers and doctors, we need to ⁇ a true dialogue that allows for better management of the hospital, better management of financial costs and medical practices. I think this technique is indispensable in those companies that hospitals have become today. The dialogue between the medical body and the manager must be made. If it is not done, it is of course at the expense of financing, therefore at the expense of the patient’s situation. It is a good thing to force it by law. The work of the task force has highlighted this lack of trust between hospital managers and doctors. This trust must be restored. Forcing it by the law is therefore not a bad thing.

In conclusion, I would say that we are obviously very satisfied with one last point, which concerns the principle of the annual growth of the administration costs of the insurer organisations as well as the variable part of these administrative costs which will be expressed in a fixed percentage from 2004. We are satisfied because from now on the rules will be transparent and the weight of the financial responsibility of mutualities on the quality of their work increases. This is obviously important and we welcome it, as well as the whole of this bill. I thank you.

The next speakers on the list are Mrs. Avontroodt, Mrs. Gilkinet and Mr. Vande Walle.

( ... ...

Mr. Tante had nothing against you.

We always keep a safe distance, right?

The optimum use of the budget in healthcare has always been the goal of our party. We have always taken the output of a policy measure in terms of health gain for the individual patient as guidance. We have always considered the price.

Mr. Minister, Mrs. Minister, I am convinced that with this law we take a number of steps to actually work with health goals. The law provides a number of instruments. Health goals are still not at the forefront. Budgetary objectives still sign a number of policy measures.

In this general discussion, I would like to make a brief reference to Article 10, which we have not expressly discussed in the committee, which empowers the King to make decisions on dialysis. Mr. Minister, Mrs. Minister, there is indeed consultation, there is a tripartite working group, there would be a consensus. Unfortunately, however, the government limits itself to the agreement that will be reached in the corresponding committee Hospitals and Hospitals Funds. Although the doctors, of course, also sat at the table, they are not involved in the consultation before the King has settled the matter. I would like to ask the Minister again whether the doctors will be involved in the consultation. They should not be overlooked. In health care and dialysis, together with the other parties, they have practically put the story on their feet in accordance with the guidelines. If there is one group where there has been very solid consultation, it is the group of doctors. I now address primarily the Minister of Public Health because that committee has dealt with that department. So why are the doctors not mentioned in the draft? Next, I come to Article 11 of the bill, which represents a trend break for hospital policy. Indeed, from now on, reference amounts will be effectively introduced for a number of medical services performed under standard procedures. Our party can fully reconcile with this. This is an effective trend break, and as Mr. Nothomb said, "On arrive plus vite and marchant lentement". Indeed, I believe that the introduction of reference amounts with a proper definition of the pathologies concerned can lead to a rational allocation of the funds in the long run. Their

Also with the establishment of the multi-party structure and the initiative for responsibility, our party is fully in agreement. We, of course, do not like conflicts and also in this design there are a number of articles in which possible dust to conflicts is hidden. I refer here to the refund amounts and their distribution. Who will ultimately pay the bill? You will not blame me, Mr. Minister, that I refer here to those who determine the health policy in the field. However, guarantees should be incorporated so that doctors cannot be held accountable for services that they would be required to perform or for which they would be instructed in certain hospitals. After all, you know that this is happening and this design can put on the abuse pile and perk. The condition is that the invoice cannot be transferred completely to the doctors.

In connection with the shared responsibility of hospitals and doctors, we would like to thank Mr. Mailleur as well as the government and the committee. We are pleased that this item has been included in the bill. I believe this is a fair measure and it is our concern to design a health policy in which all partners can participate with enthusiasm and also find satisfaction. Their

The relationship between doctors and hospitals remains, of course, a delicate point. According to the bill, the government would set up a financial committee in every hospital. I am convinced that this is a positive point to finally implement the long-seeked transparency. This committee, which is jointly composed at the request of our party, can contribute to this. In this case, a financial expert may be invoked. Doctors are not financial experts. It is often said that health policy is the soft sector but I think the members present here know very well that this is a hard sector, also financial, which requires the necessary financial expertise to occasionally see the trees through the forest. The transparency embedded in the draft law is ⁇ beneficial here. This will ultimately lead to a credible health policy, allowing us to fully support this design.

I would like to conclude the chapter on the payments and the correct relations between hospitals and doctors. Article 139bis of the Hospital Law has long been a delicate issue. I am confident that the Government will fulfill its commitments in this regard, in such a way that there is a correct retention of the centrally collected fees against the actual costs incurred in connection with the performance. This remains a point of attention. We want the government to take initiatives in this regard.

Mr. Speaker, allow me to go into this; I would like to stay with the method of accurate information.

Ms. Avontroodt asked in connection with Article 10 how it is with the consultation we are conducting on dialysis. We have talked about this for a very long time with the three parties around the table, the doctors, the hospital managers and the hospital funds. This did not lead to a solution. Honestly speaking, in the context of the work led by Mr. Perl, it was ⁇ one of the files where the impasse was most obvious. We did not touch out there. We have discussed this before and I will not go into details. I subsequently made a proposal to maintain the fees, but to distribute them differently in such a way that one type of dialysis is not favored over another. On the other hand, we are distributing the mass we now allocate to hospitals through the hospital charges, in a better way to give a more correct incentive. On the first point, the better distribution of the remuneration amount, the Technical Medical Board should issue an opinion. That advice is already in place, but I can not yet answer it, since I myself have not read it yet. As regards the second point, the distribution of hospital charges, I know that the agreement committee hospital-hospital funds is not out of it. There is no agreement. That is precisely why we need this article. Somebody must ultimately decide. No one will be happy and the minister will decide.

There is a lot of talk about and the opinions and the various elements of blocking in the conversation are ⁇ clear. Of course, I cannot stand still on this. I need to make a decision that at least gives us the incentive for more efficient practice, both in terms of fees and hospital fees. So I will eventually have to make decisions myself and that article should enable that.

There has been a lot of contact with the nephrologists and there have been extensive discussions that, however, have not led to a consensus.

Mr. Minister, I would like to replicate this. Why do you only ask for the advice of the agreement committee of hospitals-hospital funds?

This is about hospital fees. The multiparty structure would actually be a good structure to discuss that issue with the three parties around the table. If we are only talking about hospital charges, then it is the agreement committee that should advise me on that. I feel where you want to go. I also agree with that. It is typically a matter in which one has to get the three parties around the table and hold until they reach an agreement. Per ⁇ that is a question that we should once address in the multi-party structure.

Thank you, Mr. Minister, I think this proves the usefulness of a plenary session in the Chamber.

I came to the second positive point of this Health Act, in particular the measures taken in relation to the first line. Other colleagues have already taken the word extensively on this subject. I think this corresponds to the desires that have been living for a very long time. A number of resources are made available in relation to qualitative and quantitative requirements for practice. Both ministers responded that it was not intended to favor any form of practice but that it is indeed a matter of qualitative requirements. It is the concern of my party that solo practices, which are subject to the same qualitative requirements, would be equally eligible for the revaluation carried out by this law. This is a sign of faith, a confession of faith that I would like to repeat here. The revaluation of the intellectual act remains on the agenda. The question remains also what form that revaluation will take exactly. Our party has also called for much attention to the fact that this requires a re-alignment of the nomenclature. I think that revaluation of the intellectual act will be an important policy instrument.

We then come to the mandatory collection of the brake money in the hospital's emergency services. There has been an important and correct discussion on this subject. Almost all actors involved in health policy are accountable: the providers, the hospitals, the hospital funds and the scientists. It is therefore no more than normal that a first step is taken towards the responsibility of the patient. If a long-term policy is to be implemented, it is necessary for the patient to be aware of the cost of their care. Responsibility of the patient is needed. Mr. Mayeur, this does not mean that the social corrections are unjust. It is therefore important that an evaluation is made with the determination of the correct indicators and, of course, also with attention to the social indicators. We are in favor of efficient allocation of resources: the right care in the right place. Ms. Descheemaeker also made a number of comments on this subject. The report of this evaluation should effectively take into account the social indicators.

Through the opinion of the State Council, we have been able to get acquainted with the elements in the draft that we will address after the recession. Here too, I think that for an efficient allocation of the resources, the knowledge center set up by the government will prove to be a very valuable tool. As a result, a trend breakout is possible both in terms of responsibility and in terms of policy measures. Of course, our party supports this. We have submitted a proposal for this in the House and we are grateful to the Government that it has entered into it. Their

The debate that we still miss is that about the waste of funds in healthcare. Where is it? Beyond all party boundaries, people think that so much is wasted in health care. I have not given that opinion. In healthcare, resources are needed and they must be used efficiently. We cannot ignore the needs of innovation, aging and patient demand. If health care — Mr. Goutry, I’m going to use an English word — becomes consumer-driven, it also means that the responsibility of the patient will also have to be shaped. It cannot be that good health care or the best health care is deprived of the patient. He has a right to that. We create that right and anchor it even in a law. That is, the patient as a full-fledged partner in health policy gets his share, with rights and duties resulting.

Our group will ⁇ support this draft. We see this as a good initiative to evolve towards an efficient allocation of resources in health policy. We once again invite the government to ⁇ health goals in the long term rather than budgetary goals in health care.

Mr. Speaker, Mr. Speaker, Mr. Speaker, first of all, I would like to draw attention to the many positive measures that this bill contains.

Some of these measures aim to improve the control of hospital data. Others reinforce the front line by organizing the possibility of funding generalists for a whole range of functions. There is also the measure that allows to accentuate the role of generalists in the INAMI instances.

The bonus provided for generalists who meet quantitative and qualitative criteria in their practice, the availability fee, the intervention allocated to physicians for the use of telematics and finally, the mandatory insurance that pays the fees of approved generalists for the management of the medical record, are very good measures that will allow generalists to be even more active in the field and that will strengthen the front line.

Beyond this, we will have to ask ourselves — others have said it before me — about the strengthening of the intellectual act. Indeed, if all these measures go in the right direction, they will not be enough. This issue will soon have to be discussed.

I would also like to share with you two persistent concerns from my group. by

The first one concerns the package for emergencies. I have spoken on this issue in the committee. by

You know that Ecolo is not very favourable to such a measure if it does not take into account all the parameters that lead the patient to make use of emergencies and therefore to use a powerful tool when it is not necessary. by

During the discussion in the committee, we admitted that this problem could not be solved by the simple package. We were also able to see the link with one of the measures relating to generalists that I talked about a moment ago. Everyone knows that this problem is complex and requires the implementation of different techniques.

Furthermore, when we look closely at emergencies, we see that a large part of the public that makes inappropriate use of emergencies, is socially and economically disadvantaged. Our group, therefore, does not want the measures taken to eventually reduce access to care for this public. by

It is true that the possibility of imputing the package in the maximum to be invoiced was introduced.

This is the first correction. In addition, an evaluation of this measure will take place within two years, taking into account, as Avontroodt said, the social characteristics of the public. These amendments are important. However, I would like to ask you, Mr. Minister, if you could not attach to the report on poverty a report on the financial accessibility of the most disadvantaged.

You know, I am very supportive of small assessments. I am therefore pleased that an assessment is provided in the law. However, given that the problem of access to emergencies goes beyond the framework of the package, it seems to me that an assessment that would only take into account the package and emergencies will not allow to visualize, in all the measures taken by the government, whether access to care is favoured, what are the limits and where there are still difficulties.

The second concern relates to the question of responsibility. This is not addressed fundamentally in the bill. It should be the subject of a deeper discussion at the return. For us, this point is important. Mr. Minister, we would like to encourage you to continue the reflection with the sector in the way of control. It is clear that we would like to see you reach a consensus on this point. by

In addition, we would like to take the opportunity to draw your attention on two points. First of all, we advocate that the system that will be put in place in the evaluation allows to visualize what falls under the infringement, administrative error and overconsumption. by

Therefore, we are not in favor of a monolithic system. This is why we believe it would be appropriate to separate medical recommendation and medical control. Both functions are essential. Both should be developed, but linking them in the same service would not ensure the necessary independence of these functions. A field of thought opens up here. by

I would like to hear your opinion on the two suggestions I have just submitted.

Many members present are part of the Public Health Committee, which is scheduled to meet this noon. For your information, I will now give the floor to Mr. Vande Walle and then to the Minister for a short replica. I will then close the general discussion to resume with the discussion of the articles at 14:30.

Mr. Speaker, Mrs. Minister, Mr. Minister, I will be brief, because after the speech of my group friend, colleague Goutry — who spoke with his well-known diligence and expertise — I only have a brief explanation of my concern about the attention to the primary care and the attention to the general physician in this whole.

When we started the general discussion in the committee, I asked for an answer on a number of items that are very important for first-line care today. We talked about the volume increase in care and consumption, otherwise overconsumption of medical care. Their

For the general practitioners, I asked to take care of reducing the administrative burden and to pay attention to the social aspect of the consultations. I mentioned the duration of the contact between the doctor and the patient. Their

I also talked about the completion of the job, both in terms of content and availability. Due to the change of mentality among young doctors and the feminization of the professional group, we see that a number of changes are taking place. Their

During the replica of the minister, I was served on my tips, because her answers gave positive incentives.

In the draft law we also see a number of incentives to resolve the items I have just mentioned. My question remains whether these triggers are sufficient, both in terms of volume and content. The response to administrative needs — such as telematics, which the Minister has discussed in detail, and the construction of the GMDs, whose law is also on the threshold of the Parliament — are indeed positive steps for the future. It is true that these steps—especially in general medical circles—will not be welcomed everywhere and not by everyone. This seems to us logical because the need and demand will always be greater than what is offered. Therefore, the discrepancy between that question and the answer remains. Therefore, we must take care that the primary care providers — especially the general physicians — do not allow them to massively mislead it, as we have already been able to see in the media more than extensively. In the future, we must take care that our medical students do not skip the general doctor option because of the weak social status and financial benefits, which at the moment do not outweigh the requested or requested care provision and overcrowding by the patient.

We have listed a number of possibilities to bend the negative spiral with regard to the medical profession. I refer to the recognition of the family physician circle, which is in the meantime a fact, which highlights the cooperation in primary care. We also talked about the specific budget for general practitioners, the administrative simplification and – last but not least – the responsibility of patients, which in the future will become a very delicate point. Their

I would like to mention a few other points that we believe require special attention.

First of all, I am talking about the emergency service, which was also pushed forward by other colleagues. Secondly, I refer to the reference amounts to be applied and, thirdly, to the composition of the functioning of the multiparty, for which we have left a few amendments behind in the article-by-article discussion.

I am close to the fact that there are a lot of technical adjustments that, on the one hand, seem useful and necessary to me, but on the other hand, also give me the impression of sitting in a grey zone. Mr Goutry has been widely referred to in the committee discussions — and ⁇ also in his presentation in the plenary session. Given the importance of the Health Care Act, it cannot be stressed enough that in the future it will be our concern to release sufficient budgets and also to ensure that they can be used efficiently and efficiently for both the doctor and the patient.

Mr. Speaker, before concluding with a general comment, I will address two point points that were raised by Mrs. Gilkinet. by

You are right to say that there should be a monitoring of accessibility to care. This has already been done in part, but not adequately. I will therefore contact my colleague, the Minister responsible for Social Inclusion, to examine how to improve the tools we have and better control accessibility. by

For the other project that we will examine in autumn and which concerns the accountability of service providers, you said that it is necessary to distinguish between an error, an infringement and overconsumption. This idea is interesting. Juridically, it is not always possible to distinguish these notions, but this distinction is very important for understanding things. One of the shortcomings of the text I submitted is precisely the lack of clarity in the way things are presented. There is an impression that administrative errors will be considered as serious infringements. I will therefore try to clarify the accountability and improve the legal text of the project in question.

You have this that it failed to dissociate control and evaluation. It is a debate that is more complicated. It is necessary to nuance this idea. You repeat what I already have this to M. and Bacquelaine. I launched a concertation on this subject. Prochainement, you publish a note visant to revoir and profondeur the project relating to the responsibility of the service providers. I hope therefore to be able to introduce and autumn a project that will be amended in a significant way. I think the various explanations show that for us there is a project in the true meaning of the word, namely the translation of a policy vision into legal texts where there are a number of balances that must also be in place. Thus, on the one hand, the efficiency will be increased, including by more closely monitoring the efficiency of spending in, among other things, hospitals, and, on the other hand, a number of conditions will be established to make the practice more efficient by improving the support of the general medical care and by elements such as a availability fee. On the one hand, there is the idea that in the emergency services of the hospitals to the people the signal that it is sometimes better to consult the general physician and on the other hand there is a prior strengthening of the organization of the general physician guards. These balances are included in the project. This balance is also a necessity. The concern for the protection of the patient along with the concern for the quality and effectiveness of the practice are subjects of a debate that I will not return to. Their

More importantly, this draft creates a legal framework that must be completed by decisions and consultation procedures. In this there lies an important responsibility with the organizations on the ground, with the medical trade unions, with the mutualities to replenish the number of opportunities created. I am thinking of creating a specific specificity for general medicine, within the Technical Medical Council in the RIZIV, within the medical mutualist discussions. We make this possible now. It is of course up to the doctors themselves to complete and clarify it.

Mr. Speaker, in conclusion of this debate, I would like to formulate another concern, which is not so much about the content of the draft but about the work in the committee. I found the work in the committee ⁇ useful and ⁇ constructive. We have accepted many amendments, both from the opposition and the majority. Such were much more than mere text improvements, there were also important substantive amendments. I would like to thank the members for this. One may wonder how it is possible that a draft that was recently submitted to the Chamber and for which not much time could be allocated for discussion, has yet been the cause for such a quiet, constructive and thorough discussion. I think it has to do with the quality of the chairs of the two committees involved. Mr. Wauters apologizes, but we have had a very good presidency in this mixed work. It also has to do with the quality of the members. But it ⁇ also has to do with the fact that many themes of the draft have been discussed in the committee for a whole year following hearings, thematic discussions and oral questions.

I feel like we can learn something from it. We anticipated much on the content of this draft through discussion techniques that were not so much related to legislative work but rather to hearings, thematic discussions, oral questions. This has made it possible that in the committee a kind of common knowledge and expertise has grown, which one might envy us in other committees. However, this has mainly led to the fact that one can have a very technical design, a very constructive and where necessary business discussion.

At the same time, I think that a number of fundamental concerns such as the quality of health care, its accessibility and its effectiveness are still being asked by these two committees beyond the boundaries of majority and opposition. This does not mean that we always agree and that the fulfillment of some of these measures will not again lead to discussion and controversy. However, this is inevitable. I think Mr. Valkeniers has rightly emphasized this.

I would like to thank the members. I look forward to the discussion on the articles this afternoon. I say this also on behalf of Mrs. Aelvoet, with whom I have conducted this debate and who has had exactly the same experiences as I have had with regard to the nature of the work.