Proposition 51K1627

Projet de loi relatif à la maîtrise du budget des soins de santé et portant diverses dispositions en matière de santé.

General information ¶

Submitted by

PS | SP MR Open Vld Vooruit Purple Ⅰ

Submission date

Feb. 22, 2005

Official page

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Status

Adopted

Requirement

Simple

Subjects

budget medicinal product pharmaceutical expenses health costs patient's rights social security medical institution health insurance

Voting ¶

Voted to adopt

Vooruit PS | SP Open Vld MR

Voted to reject

CD&V N-VA FN VB

Abstained from voting

Ecolo LE

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Discussion ¶

April 13, 2005 | Plenary session (Chamber of representatives)

Full source

I would like to speak slowly until Mr. President arrives. Goutry, but I don’t think I’ll last half an hour.

But you don’t have to stand for half an hour, Mrs. You have to make your oral report, that’s all.

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 like to refer to the general discussion, Mr. Goutry will talk about the discussion of the articles. And, of course, for the Socialist group, it will be mr. A major who will develop our point of view.

Our committee examined this bill during the meetings of March 8, 16, 22 and 23 and, as you said, Mr. Speaker, yesterday, April 12, 2005. To the draft law under consideration were initially attached the following proposals of law and resolution:

- the bill proposed by Yvan Mayeur and Magda De Meyer to abolish supplementary fees for children hospitalized with an accompanying parent, by amending the Hospital Act coordinated on 7 August 1987 (No. 242);

- the proposal for a resolution by Daniel Bacquelaine and Denis Ducarme, on the coverage by the social security of the costs inherent in the treatment of the child with a serious disease (No. 305);

- the bill proposed by Daniel Bacquelaine and Denis Ducarme amending the law on hospitals, coordinated on 7 August 1987, as regards the reception of children in the structures

Our committee examined the proposed bill during its meetings of 8, 16, 22 and 23 March and of yesterday, 12 April 2005.

The draft law was originally accompanied by a draft law of Mr Mayeur and Mrs De Meyer, as well as a draft resolution and a draft law of Mr Bacquelaine and Ducarme, a draft law of Mr Mayeur and Mrs Lambert and a draft law of Mr Vandeurzen and Mrs De Block.

Minister Demotte has emphasized that the growth of healthcare spending for the year 2004 could generally amount to more than 10% while the government agreement predicted a nominal growth of 4.5 percent. The draft law therefore aims, among other things, to contribute to the structural control of those expenses.

The Health Act is intended, in the first place, to amend the provisions concerning the Special Solidarity Fund. This Fund was created to prevent people from renouncing non-refundable benefits for financial reasons, which are still indispensable. The bill provides, among other things, for a smoother access to the Children’s Fund. To be able to cope with the hospitalières (No. 810);

- the Bill of Yvan Mayeur and MarieClaire Lambert amending the Hospital Act, coordinated on 7 August 1987, with a view to eliminating the possibility for hospitals to claim from patients a financial contribution for access to emergency services (No. 1095);

- the bill of Jo Vandeurzen and Maggie De Block amending the law on compulsory health insurance and compensation, coordinated on 14 July 1994, with a view to establishing a committee for the permanent review of the nomenclature of health benefits (No. 413).

At the request of their authors, the bills no. 242, 810 and 413, as well as the resolution no. 305, were disjoined during the discussion.

We first heard the introductory exhibition of Social Affairs and Public Health Minister Rudy Demotte, who recalled that the government agreement stipulates that the growth rate of healthcare spending will rise to 4.5% out of inflation.

Estimates made at the beginning of December 2004, on the basis of data up to the end of August, suggested that the overall increase in healthcare spending for 2004 could be more than 10% while a nominal growth of 5.7% was expected.

The bill under consideration contains a number of measures aimed at ensuring structural control of spending.

The submission of this bill was preceded by a consultation with the main actors of the compulsory health care insurance.

With regard to the Special Solidarity Fund, the first objective of the Health Act is to adapt the arrangement relating to this fund so that it responds more to the needs of the population. These include benefits that are not necessarily exceptional while referring to rare diseases but also on rare indications such as, for example, a fixed dental prosthesis made indispensable following the operation of a tumor of the tongue, benefits that are not expensive as such but whose frequency and complexity make care very expensive such as, for example, some bandages.

As regards the additional expenditure arising from that enlargement, the annual budget of the Fund was increased to EUR 22.4 million in 2005.

The budget allocated in the framework of home care (including the multidisciplinary consultation introduced at the level of integrated home care services) for the measures in favor of those patients is fixed at EUR 1,209.611,66 on an annual basis.

The bill contains a second set of measures to improve the ratio between the quality of care on the one hand and what is at stake budgetarily on the other. Compliance with rules or recommendations on rational prescription of medicinal products and specialist services, established by the National Council for Quality Promotion, should be a condition for accreditation. In this context, the National Commission of Physicians and Hospital Funds was asked to prepare proposals for results obligations in the field of rational prescription of medicinal products by 30 June 2005.

Finally, the Government considers it necessary to better combine and coordinate the various government initiatives relating to quality promotion. In that sense, it seems appropriate to appoint a quality advisor who can perform a bridge function between the various public institutions.

Title III of the draft law aims to promote cooperation between hospitals and to adapt programming to the real needs of the population. In this context, an area will be established within which the hospital services must meet the needs of the population.

The draft law further confirms the recognition standards and the rules regarding the maximum number of permitted medical-technical services using a PET scanner and a magnetic resonance tomograph. In that regard, it may be noted that the RIZIV will be empowered to determine whether illegal and unauthorized equipment has been installed and to act punitively in this regard by reducing the fees charged for the categories of services established by royal decree performed in the hospital concerned.

The draft law prohibits hospitals from claiming a flat-rate contribution from the patient who solidarité d'intervenir pour des prestations relevant de techniques médicales innovantes.

In addition, the bill eases access to the Special Solidarity Fund for children under the age of 19. The goal of free care for these children is confirmed.

The annual budget of the Special Solidarity Fund was increased from EUR 12.4 million in 2004 to EUR 22.4 million in 2005.

In order to ensure better patient protection, the bill also contains provisions establishing an intervention for heavy chronic care provided at home to persons with non-congenital brain injury.

The budget for these measures in favour of patients in the context of home care, including the multidisciplinary consultation established at the level of integrated home care services, is fixed at 1.209.611,66 euros.

As regards improved care and budget control, the bill contains a second set of measures aimed at improving the relationship between quality of care and budget control. The Government considers that compliance with the rules or recommendations related to the rational prescription of medicines and specialized services, which have been established by the National Council for the Promotion of Quality, must condition the maintenance of accreditation. In this regard, the National Medico-Mutualist Commission was asked to formulate, by 30 June 2005, proposals for result obligations in the field of rational prescription of medicines.

Finally, the Government considers it necessary to better collect and harmonize the various public initiatives taken in the field of quality promotion. In this context, it seems appropriate to designate, in addition to a budgetary advisor, a “quality” advisor who can perform a role of intermediary between the various public bodies, in connection with the promotion of a more efficient use of healthcare products.

Title III of the draft law under review aims to adapt, optimize and refine the law on hospitals. The first is to promote collaboration between hospitals so that they can more easily offer their services in common.

Il convient également d'affiner et d'optimaliser la logs in an emergency service, except in certain, clearly defined cases.

That possibility, which is permitted by means of a transitional measure, will disappear as soon as the brake fee is adjusted to the followed care path. The bill confirms that, in addition to the brake fee that covers the performance of the emergency doctor, no additional contribution may be requested from the patient for whom a medical emergency team was engaged. A new provision clarifies that for interventions, services and care services whose costs are covered by the budget of the financial resources, no contribution should be requested from the patient.

It was decided to include a provision authorising the King to take the necessary measures in due time in order to strictly ensure the observance of the growth standard during the year 2005. This authorization is broadly formulated, but it is limited both materially and in time.

From a material point of view, the measures should be aimed at achieving the budget target set for 2005 and “in fine” to ensure the continuity of our health insurance system. Based on the latest budget estimates available to the Government and in consultation with the stakeholders, the Government has taken the measures necessary to control the budget. If the new estimates of April 2005 show a new risk of excess, the draft law allows three types of corrective measures to prevent or reduce that risk: measures aimed at combating misuse and abuse, measures ensuring an efficient control of expenditure and measures aimed at adjusting the insurance coverage, the conditions of award and the remuneration of the medical benefits contained in the legislation. In time, the authorisation is limited to the period from 1 April 2005 to 31 December 2005.

This, of course, is not unavailable with the general purpose of consultation with the actors.

The pharmaceutical sector is characterized by an explosive increase in spending. Even before the beginning of the year, the budget was already exceeded by 80 million euros! In order to cope with such an explosive increase, effective measures should be taken. programming in order to adapt to the real needs of the population. In this perspective, a territory will be fixed within the territory of the hospital and the hospital services must serve the needs of the population.

The bill further confirms the approval standards and rules regarding the maximum number of medical-technical services, using a PET scanner and a magnetic resonance tomograph. These standards were already contained in royal decrees, but they were cancelled by the State Council due to an incorrect application of the opinion procedure before that Council.

In this regard, it can be noted that the INAMI will be empowered to establish the installation of the illegal and unauthorized device and to sanction it with a reduction in fees for the categories of benefits determined by royal decree that will be performed in the relevant hospital.

The bill prohibits hospitals from receiving a flat-rate contribution from the patient who appears in an emergency care unit. Under certain precise circumstances, however, the collection of a contribution of 9.50 euros and 4.50 euros for patients receiving an increased intervention remains possible.

This transitional possibility will end when the moderator tickets will be modulated according to the treatment path followed and will be subject to incentives encouraging the patient to resort to first-line medicine.

The bill confirms for the rest that apart from the moderator ticket covering the services of the emergency doctor, no additional intervention can be claimed from the patient for whom a mobile emergency service, the SMUR, has intervened. A new provision is additionally added to the Hospital Act to clarify that for interventions, services and care services whose costs are covered in a flat-rate manner by the budget of the financial means, there can be no demand for intervention from the patient.

The bill also includes a temporary one-year moratorium on existing agreements between the medical council and the hospital manager in relation to retention on fees.

Dans la note relative au budget soins de santé 2005 et au contrôle structurel des dépenses, approuvée The general objective of the measures is to maintain a system of health care, where it is still possible to invest in innovative research on new medicines. If one wants to be able to invest in new medicines, one must save on the old treatments. The government wants moderate growth. The medicines with an increase of 13% in 2005, receive more than their share of the growth.

The therapeutic freedom of the doctor is an essential feature of our system. The free choice of the most appropriate therapy — in the spirit of rational use of the funds of health insurance — will be ⁇ ined. Therefore, for a real renewal, an adjusted refund will always apply.

There must be constant search for new means of saving. The New Zealand system, and more specifically the offer request, is an innovative instrument that the Minister in Belgium wishes to use. This instrument offers the advantage of being able to reconcile the control of public spending with the market mechanisms, as the undertakings themselves determine the acceptable price based on the market. The Minister is committed to introducing this mechanism of the tender request to refund not only the cheapest medicine. He sees it wider. All medicines will still be refunded, but for the cheapest medication, the refund will be higher.

The call for tender will take place within the framework of a group revision procedure in the Committee on Medicines Acceptance. A first extension of the reference refund shall take effect from 1 July 2005; all forms of a non-patented molecule shall be taken into account for the reduction of the refund basis, which increases from 26 to 30 %.

In 2005, a more fundamental reform will be implemented. The reference refund may be extended on a case-by-case basis to include groups or "clusters" of therapeutically interchangeable specialities.

De minister kondigt een andere belangrijke nieuwigheid aan: het principle van de "disconnectie" tussen de terugbetalingbasis van een geneesmiddel in de publieksprijs. By the Government on 26 November 2004, it was decided to introduce, in a draft law "Health", a provision by which the King would be authorized to take timely measures to ensure strict compliance with the growth standard in 2005. This qualification, if it is formulated broadly, is limited both materially and temporarily.

From a material point of view, the measures to be taken must be aimed at achieving the budgetary objective set for the year 2005, the control of the budgetary objective and the guarantees of proper use of resources are indispensable in order to ensure the sustainability of our health insurance system. Based on the latest budget estimates in its possession and in consultation with the actors, the government has taken the necessary measures for this budgetary control. A new estimate of expenditure is scheduled at the beginning of April 2005. If these new estimates show a new risk of exceeding, Article 54 of the bill will allow to take, within a short period of time, the corrective measures necessary to avoid or limit this risk.

For this purpose, the King will be able to take three types of measures: measures aimed at combating improper use and abuse; measures guaranteeing effective control of expenditure and measures aimed at adapting the intervention of the insurance, the conditions of award and the fees of health benefits provided for in legislation.

In terms of time, the use is limited to the period from 1 April 2005 to 31 December 2005. In doing so, it can be taken into account the development and assessment of the 2004 expenditure and the first estimates of the development of the expenditure in 2005.

This obviously does not contradict the general objective of a consultation with the actors.

As for the pharmaceutical sector, it has experienced a real explosion of spending. Even before the beginning of the year, the excess of the 2005 budget was already guaranteed at a rate of more than 80 million euros. In the face of such an explosion, effective measures must be taken.

The general objective of measures is to maintain a system of health care that can still be paid for innovations and medicines. Si on veut pouvoir investir dans les nouveaux The purpose of that principle is to have a more effective means of pricing the new medicines. It is very important to ensure that the patient is financially protected, but also that he is properly informed.

The use of health-related information campaigns for commercial purposes will therefore be regulated.

Then I come to the presentation of the applicants of the combined proposals of resolutions and legislative proposals.

Mr Denis Ducarme clarifies that the bill no. 810 aims to improve the reception of children in hospitals by providing that special standards may be imposed on hospitals and pediatric departments.

According to Ms. Maggie De Block, the control of the healthcare budget requires that one first has sufficient scientific data to enable a correct reimbursement of the healthcare performance. The Bill No. 413 aims to establish a Committee for the permanent review of the nomenclature of medical benefits.

Mr Yvan Mayeur recalls that the law of 22 August 2002 provides that hospitals can claim a flat-rate contribution from patients who register in an emergency care unit. This flat-rate contribution was fixed by royal decree at 12.50 euros and should prevent people from unnecessarily resorting to an emergency service. In practice, hospitals have responded differently to this provision. Mr Mayeur therefore proposes to repeal Article 107quater of the Act of 22 August 2002. In this regard, he refers to the judgment no. 49/2004 of the Arbitration Court of 24 March 2004, which annuls that provision. It is up to the legislator to draw conclusions from all these elements — destruction, effectiveness of the provision — and to abolish the contested article in the future.

What Wetsvoorstel nr. 413 betreft, specified of minister dat nu al two instances zich bezighouden met de herziening van de nomenclatuur: of commission artsen-ziekenfondsen en de Technische medische raad. For truly innovative medicines, we need to make savings on the old treatments that have been depreciated by the industry. Only by limiting spending on existing therapies will patients be given access to new medicines.

The government is not in a logic of reducing spending on medicines but of moderate growth. It should not be forgotten that the healthcare sector benefits from a not negligible growth rate of 4.5% and that drugs with an increase of 13% in 2005 have more than their share of growth.

The therapeutic freedom of the doctor is also an essential feature of our system. The freedom to choose the most suitable therapy - in the spirit of rational use of the means of health insurance - will be preserved. A real innovation will always benefit from an adequate reimbursement. This will no longer be the case of "me too", those molecules copying an existing molecule or the new forms of the same molecule.

The Minister is aware of the absence of a miracle solution: as such, the replacement of the Belgian system by the New Zealand model taken as a whole, is ⁇ not his goal. On the other hand, it is necessary to be creative and new tools to ⁇ savings must be constantly sought.

The New Zealand system and more ⁇ the tender tool is an innovative tool that the Minister wishes to be able to use in Belgium. This tool has the merit of reconciling both state spending control and market mechanisms, since it is the firms themselves that decide the acceptable price level according to the market.

Of course, New Zealand and Belgium cannot be compared. That is why the Minister proposes to use the tender mechanism not to refund only the cheapest medicine but in a wider way. All medicines will continue to be refunded but the lowest price will benefit from a better refund.

The call of tenders will take place within the framework of a procedure of revision of the group at the level of the Commission for the refund of medicinal products. On se rend compte que la Belgique est restée timide dans l'utilisation du remboursement de référence. When it comes to hospital pediatrics, the minister knows that there is a shortage in the organization and financing of this sector. At the moment, there is no precise planning. Nevertheless, the efforts in the field, as well as the rural or urban character of each zone, will be taken into account. Measures should also be taken to improve the quality of childcare. Furthermore, the reflection on the adoption of children should not be separated from the debate on the development of care regions.

What a Bill No. 242, the government is very committed to the honorary supplements in hospitals. In addition, the Minister has asked the National Council for Hospital Services for an opinion on this issue. A ban on honorary and room supplements for accompanying children is ⁇ an interesting idea, but one should also examine the consequences such a measure may have on other billing items. In particular, it should be examined whether that measure cannot discriminate against children whose parents are less accessible.

Finally, as regards the habit of unnecessarily reporting to the emergency services, the Minister specifies that the bill has a different starting point than Bill No.1095.

I come to the general discussion.

As regards the Bill No. Mr Goutry notes that everyone has been asking for a revision of the nomenclature for years. It is paradoxical, on the one hand, to provide for the function of “delegate” in order to promote a higher quality of medical practice, and, on the other hand, to oppose the establishment of a committee for the permanent evaluation of the nomenclature.

In connection with the Bill No. 242 the same speaker emphasizes that, before 2002, there was a good regulation on supplementary fees, but that it was abolished. He also points out that the bill contains an impressive set of powers that are unprecedented.

The minister disputes that the authorization can be labeled as "power". The text is merely an instrument that can prevent the current excesses from occurring again. The Parliament shall be notified in advance of the royal decrees implementing Article 54 and must ratify those decrees before 31 December 2006. extension of the reimbursement of the reference shall enter into force from 1 July 2005; all the forms of a non-brevet molecule shall be taken and accounted for the reduction of the basis of the reimbursement, which passes from 26 to 30%.

The Minister adds that a more fundamental reform will also take place in 2005. Like our neighbors, the Dutch and the Germans, the reference refund may be extended on a case-by-case basis to groups or "clusters" of interchangeable therapeutic specialties.

The Minister announces another important novelty: the introduction of the principle of "disconnection" between the basis of reimbursement of a medicine and its public price. This principle aims to have a more efficient tool in the setting of prices for new medicines.

Furthermore, withdrawal from the reimbursement system unilaterally decided by the firms – the contraceptive pill for example – will no longer be tolerated.

In an increasingly complex context, it is essential to ensure that the patient is financially protected but also to ensure that he is properly informed.

The misleading use for commercial purposes of health-related information campaigns should therefore be regulated.

I come to the exposition of the authors of the annexed draft resolutions and legislation.

by Mr. Denis Ducarme specifies that the Bill No. 810, which he co-authors, aims to improve the reception of children in hospital structures by providing, in the Hospital Act, that special standards can be set for hospitals and pediatric services. It is necessary to provide for a living space within hospitals more adapted to the needs of hospitalized children.

Ms Maggie De Block, co-author of the proposition of law no. 413, indicque que, pour maîtriser le budget de l'assurance maladie, il convient de disposer de suffisamment de données scientifiques permettant de rétribuer correctement les prestations de santé. La proposition de loi, dont l'intervenante est coauteur, entend créer un Comité pour l'examen permanent de la nomenclature des prestations de santé. Ms. De Block rappelle que l'examen de Mr. Goutry refers to the opinion of the State Council. In that regard, he nevertheless finds that the King is authorized by the draft law to take all possible measures. Therefore, it is essential to have accurate figures. On the component "drugs" the speaker has a more nuanced position. It is therefore desirable to organise a hearing with the relevant authorities.

Ms. Detiège believes that the bill should not trigger panic reactions too quickly. The draft law contains very favourable measures, such as those relating to the Special Solidarity Fund. The CTG has repeatedly advocated for a reform of the reimbursement scheme for medicines. If an option is made for a procurement-based scheme, this must be done in accordance with legally fixed rules. On the other hand, the speaker acknowledges that the bill provides the possibility to take action against pharmaceutical companies who wish to withdraw from the refund scheme.

Mr Drèze considers that Parliament cannot adopt such a draft law without knowledge of the case and that hearing should be organised.

Mr Bacquelaine acknowledges that the granting of powers in relation to healthcare does indeed involve risks. According to him, this is not the most appropriate time for hearings.

Mrs Avontroodt refers to the goal of keeping our social security system viable. It considers it appropriate that the committee organizes hearings on the international aspects of the drug policy.

Mr Bonte notes that the powers granted to the King by this draft law are not exceptional and refers to the special tax and social powers granted in 1993 and 1997. The speaker believes that organizing hearings would be mere waste of time.

Mr Mayeur considers that the committee should not replace the government, which has already engaged in consultations, which, by the way, has resulted in certain measures included in the draft law. Therefore, it seems pointless to hear him again. This proposal was initiated by the Social Affairs Committee.

by Mr. Yvan Mayeur recalls that the law of 22 August 2002 on measures in health care, adopted during the previous legislature, provides that a flat-rate contribution may, in accordance with the conditions fixed by the King, be required by hospitals from patients who appear in an emergency care unit. This flat-rate contribution, fixed by royal decree at 12.50 euros, aims to tax the undue use of emergency services.

In practice, this provision has been applied very differently by hospitals. by Mr. Mayeur therefore proposes to repeal Article 107quater of the law of 22 August 2002 and refers in this regard to the judgment no. 49/2004 issued on 24 March 2004 by the Court of Arbitration, which annuls this provision but ⁇ ins its effects until 31 July 2005.

If the effects of the provision are ⁇ ined until 31 July 2005, it is in order to avoid administrative difficulties that would result from the retroactive effect of a pure cancellation. In this case, Mr. Mayeur understands the willingness to prevent such cancellation from retroactively acting. However, it is permissible for the legislator to draw the conclusions of all these elements (cancellation, lack of effectiveness of the provision) and to repeal, for the future, the contested article.

I now explain to you the position of the Minister of Social Affairs and Public Health with regard to the attached bills and resolutions.

Regarding Bill No. 413, the Minister specifies that two bodies are already permanently dealing with the revision of the nomenclature in Belgium: the Medicomut and the Medical Technical Council. Therefore, it is unnecessary to establish an additional body.

Regarding the reception of children in hospital structures, the Minister does not ignore the discomfort existing in the organization and financing of hospital pediatrics. At the moment, no specific planning (i.e. fixing a number of pediatric services per Region) has been developed. It is clear, however, that the efforts made on the ground will be taken into account, but also the rural or urban character of a given area.

The program of pediatric care must also include measures capable of improving the quality of the reception of children. Par ailleurs, la réflexion sur l'accueil des enfants dans He disagrees with the proposal to organise hearings, as the draft royal decree will be submitted to Parliament. He considers the fears of some that this bill will jeopardize the Belgian consultation model unfounded.

The minister is surprised that some people question the seriousness of the budget surpluses, while they have strongly urged the government to do something. In addition to the structural problems, there are also methodological problems. In this context, the task that will be assigned to the Court of Auditors, in particular the development of a methodology to make the long-term budget formulation more efficient, is essential. In addition, an internal review will also take place, which should identify what can be improved in the short term. The government only has the accounting data until the end of October 2004, and therefore still does not have definitive figures. These figures indicate an increase of 10% (600 million euros), while an increase of 5.7% was allowed. The authority granted to the King by Article 54 of the draft law shall be exercised by a decision adopted after consultation in the Council of Ministers.

Mr Bacquelaine repeats that the essence of the Belgian system, in which decisions are taken in consultation with the actors, must not be touched. He regrets that a number of measures were not included in the law, which belonged to it because they could lead to an efficient use of the budget. According to him, the problem of the brake money needs to be looked at again. Furthermore, the rules on therapeutic risks and medical liability should be further developed. The freedom of choice of the patient and the freedom of the healthcare provider should also be ⁇ ined.

He has been advocating for years the idea of cooperation between the different hospitals. There is currently an experiment in this direction. The Federal Knowledge Centre would also need to redefine the programming criteria for the PET scanners and adapt them to the evolutions. The moratorium on the advance reduction by the hospital on the honoraries of doctors is a good measure to prevent overconsumption.

Met betrekking tot de artikelen over de geneesmiddelen, hat de spreker echter wel een aantal opmerkingen. De moleculen van de nieuwe the hospital structures should be put in parallel with the current debate on the organization of care pools.

Regarding Bill No. 242, the Minister stresses that the government is very sensitive to the problem of supplements in hospitals. The Minister has also submitted a request for an opinion to the National Council of Hospital Institutions on the whole problem of hospital supplements. This opinion should be given within three months.

While the prohibition of requesting supplementary fees and rooms for accompanying children is an interesting idea that should be considered, it is also necessary to examine the indirect effects such a measure could have on other billing points, as well as its possible discriminatory effect against children whose parents are less available.

Finally, as regards the abuse of emergencies, the minister specifies that the bill under consideration favours another option than that held by Bill No. 1095.

I come to the general discussion.

Referring to the Bill No. 413, Mr. Luc Goutry points out that everyone has been asking for years for a revision of the nomenclature. It is paradoxical to create the function of “delegate” in charge of promoting the quality of medical practices but to oppose the establishment of a committee for the permanent review of the nomenclature of health care benefits while this area constitutes the Achilles heels of health insurance.

According to Bill No. 242, Mr. Goutry emphasizes that, before 2002, there was good regulation on supplements. However, in 2002, this regulation was removed, despite the protests of the group to which the speaker belongs.

by Mr. Goutry notes that the bill under consideration contains an impressive series of special powers, of an unprecedented scale in his parliamentary career.

Le ministre conteste le qualificatif de pouvoirs "spéciaux" pour désigner l'habilitation conférée au Roi par le projet de loi. Le texte à l'examen ne constitue qu'un instrument de nature à éviter que ne se répètent les dépassements actuels. Les arrêtés royaux qui seront pris et exécution de l'article 54 medicinal products must be truly innovative and must create added value for the patient. However, when a system of public procurement is initiated, the supply of medicinal products in Belgium should not be restricted in such a way that there would be insufficient choice. While it is necessary to rationalize prescription behavior, this should not lead to a situation in which patients would no longer be able to obtain the medicines most suitable for them. This would lead to a two-speed medicine.

The Minister clarifies that a number of things have already been accomplished. The pharmaceutical industry in Germany is one of the most developed in Europe and the world. There, a reference refund is applied which is bound to a cluster. The re-grouping of indications as a whole should be based on a scientific basis. Their

Mr Bultinck points out that the bill that is currently being discussed has far-reaching implications. At the beginning of his mandate, the Minister has organized the health-related dialogue that has yielded few concrete results. In the autumn, a number of questions were asked about the financial situation of healthcare. But it was only in November, after the publication of a number of alarming reports, that the minister for the first time spoke clear language and formulated a number of concrete proposals.

The Vlaams Belang group is of the opinion that the financing of social security and also the health insurance should come more from the general resources. There is a symbolic struggle against the pharmaceutical sector and that is not good. The debate on health care needs to be carried out seriously. The group is not in favour of a privatization of healthcare.

The Minister is of the opinion that behind the debate on regionalization the debate on privatization is hidden. He is opposed to regionalization.

For Ms. Avontroodt, there is currently a legitimate concern in relation to the drug policy. The Belgian pharmaceutical sector plays an important role in terms of innovation, employment and economic growth. The Minister must take this into account. According to the Commission, there is a risk of two-speed health care and it will be communicated to the Parliament who must confirm them before 31 December 2006 in order that they can continue to solve their effects after that date.

Referring to the opinion of the State Council, Mr. Goutry notes, however, that the bill allows the King to take all possible and imaginable measures. Therefore, it is essential to be able to have precise figures.

As for the “medicines” section, the speaker says he is more nuanced. Therefore, the hearing of the main actors in this area, i.e. the institutional actors, should be organised.

Ms. Detiège believes that the bill should not trigger panic reactions too quickly. In addition, the project contains extremely positive measures, such as those relating to the Special Solidarity Fund.

Regarding the system of reimbursement of medicines, the interviewer recalls that the CRM has already, on several occasions, pledged for a system reform. Furthermore, if a decision is made to use the tendering system, it should be done in accordance with specific rules on the legal level. For the rest, the speaker welcomes the fact that the bill gives the minister the means to react with respect to pharmaceutical companies wishing, at the expense of public health, to exit the refund system.

by Mr. Drèze also believes that Parliament can only adopt such a bill with knowledge of the cause. The speaker is also in favour of organizing hearings.

by Mr. Bacquelaine acknowledges that the assignment of special powers in the field of healthcare is not without risk for the model of consultation that is ours. As regards the proposal for the organization of hearings, the speaker considers that the moment is not the most favourable.

Mrs Avontroodt refers to the Minister’s goal that is to maintain the sustainability of our health care system. However, she stresses that it would be appropriate for the Commission to organise a day of hearings on the international aspects of the drug policy from now on.

M is Bonte remarque que les habilitations conférées au Roi par le présent projet de loi ne sont pas exceptionnelles et se réfère, pour étayer son this may be restricted or restricted by the present bill. There is a lack of an instrument, which is, however, necessary to carry out budget control, and these are the data. There is no mention of the brake money either. Finally, it is time to introduce a regulation on medical liability.

Mr Nollet notes that the draft includes a number of provisions of very different origins. Regarding the introduction of a sense of responsibility among different partners, Ecolo agrees with the proposed arrangements. In the chapter on the medicines, a kiwi model adapted to Belgium is proposed. He is not of the opinion that these rules would be an attack on the pharmaceutical industry. With regard to the powers, the member agrees with the final purpose of the draft. It should be possible to act effectively in the short term. However, the way of acting proposed is not the right way. The text is too broad. For everything, a mandate is given, which will ⁇ not make the system more transparent.

Mr Verhaegen notes that no effective response has yet been given on the organization of hearings.

Mr Mayeur points out the paradoxical context of the bill. Despite the increase in funding for the healthcare budget (+4.5% in the government agreement), this remains insufficient, as costs and demand are constantly evolving. Therefore, the government should take measures to try to control the evolution of costs and expenditure in that sector without hindering access to health care. He also believes that a debate should be organised on the issue of establishing the growth standard. As regards medicinal products, he considers that credit measures support rational behavior in the prescription of medicinal products and are suitable for the purpose of raising the responsibility of the parties concerned.

Regarding the law on the hospitals, the idea of care regions and zone programming seems to be a suitable way to rationalize the medical supply in the different regions and subregions of Belgium. The establishment of fixed sums per disease enables cooperation between sectors and means a more coherent and less expensive approach. Article 29 of the draft law prohibits claiming an additional flat-rate contribution in an emergency care unit. Moreover, Mr Mayeur fears that the moratorium on taxes propos, aux pouvoirs spéciaux conférés en matière fiscale et sociale in 1993 and 1997. The interviewer considers that the organization of auditions would constitute a pure loss of time.

by Mr. Mayeur believes that the commission should not replace the government where the consultation has already taken place. This consultation with health care actors has led to the elaboration of certain measures agreed in the bill. Therefore, it seems unnecessary to hear everyone again.

Furthermore, it does not support the proposal of some members to organize hearings at the time when draft royal arrests are communicated to parliament.

by Mr. Mayeur also considers that the fears that this bill would endanger the Belgian model of consultation are unfounded.

The minister is surprised by the fact that some question the seriousness of the surpassing figures, while those have invited, with great diligence, the government to react when the first figures are published.

In addition to structural issues, some problems are methodological. In this regard, the task that will be entrusted to the Court of Auditors to define a more efficient method of preparing the budget in the long term is of paramount importance for the establishment of an optimal decision-making framework. In addition, an internal audit will also take place, allowing to see what can be improved in the short term.

The government still does not have definitive figures, but only accounting figures for the end of October 2004. These figures testify to a growth rate of 10% (600 million euros) while the allowed growth was 5.7%.

The authorization conferred on the King by article 54 of the draft law shall be exercised by decree deliberated in the Council of Ministers: any decision shall therefore be concerted by the whole of the parties represented in the Council of Ministers.

by Mr. Bacquelaine repeats that one cannot change the foundations of the Belgian system, which is a conventional system in which decisions must be taken in consultation with the actors. The interviewer regrets, however, the absence in the law of a series of measures which, however, had their place, given that they would have allowed a van de ziekenhuizen op de artsenhonoraria problemen inzake het beheer doet rijzen.

With regard to the drug policy, Mr. Mayeur considers that the introduction of a system of bidding requests constitutes a rational approach that allows for savings. He is satisfied that in the case of “piracy” of heavy equipment, the bill provides for the possibility of imposing penalties. He is also pleased that the bill definitively establishes the programming of the NMR and PET scanners.

Mr Drèze invokes Article 21, which states that where a association of hospitals is operated by a legal person, the latter may have as members only the legal persons operating the hospitals concerned. He is opposed to the introduction of an additional flat-rate contribution for patients enrolling in an emergency care unit.

Regarding the freezing of the deductions on the doctor’s fees in the hospitals, he asks that the minister should clarify how it is with the hospitals that operate on the basis of the actual costs.

Ms. Detiège welcomes the introduction of a system of public procurement and plans to review their operation after one year. Finally, she emphasizes that some original medicines today may be cheaper than their generic counterparts.

The minister clarifies that drugs represent only 17 percent of global spending, but that they are at the source of 50 percent of the budget deficit. He acknowledges that a medicinal product that came as a winner from a public procurement will enjoy a better repayment rate and therefore is advantageous. That system will also benefit some companies that market older molecules. The moratorium on the honorary wages of doctors will be established on the basis of a relative value and the rate established for the withdrawal will not be able to be exceeded, even if the hospital's turnover increases. With eight votes against five, the committee decided not to proceed to hearings.

Finally, I would like to thank the services for the work they have done on this occasion. Efficient use of the budget. The problem of the ticket moderator must, for example, be reexamined.

In addition, regulation on therapeutic risks and medical liability should be deepened.

The free choice of the patient and the freedom of the healthcare provider must also be preserved, as opposed to privatization in the United States and stateization in the United Kingdom.

The idea of a collaboration between the different hospitals, which Mr. Bacquelaine for several years already, is also the most praised. In this regard, an experiment is currently underway with the public hospitals of Liege.

The Federal Centre of Expertise should also redefine the programming criteria for PETscans and adapt them to developments.

The moratorium on the hospital’s retention of doctor’s fees is a reasonable measure to prevent overconsumption.

Regarding the proposed articles relating to medicines, however, the member makes some observations. The molecules of new medicines must be truly innovative and have added value for the patient. However, the establishment of a procurement-based system should not reduce the supply of medicinal products in Belgium to the point that there would no longer be enough options. by Mr. Bacquelaine remains perplexed about the reference in the proposed text to the "analogue and "identical" indications concerning drugs and asks the minister for explanations on this subject.

He also notes that prescribing behavior should be rationalized, but that it cannot lead to patients no longer being able to obtain the most appropriate medicines for their case. This would result in a two-speed medicine.

The Minister said a number of things have already been accomplished. The German pharmaceutical industry is one of the most developed in Europe and in the world. Germany applies a reference refund linked not only to an individual indication, but also to a "cluster". The aggregation of indications must be carried out on a scientific basis.

by Mr. Bultinck insists on the very broad scope of the bill under consideration. At the beginning of his term, the minister organized health dialogue that did not yield concrete results. In the autumn, a number of questions were asked about the financial situation of health care. But it has been necessary to wait until several alarming communications about health care deficits are published in November so that the minister can express himself clearly and formulate concrete proposals.

The speaker believes that the financing of social security should also be addressed in this context.

The Vlaams Belang Group considers that the financing of social security as well as the financing of health insurance should come more from general resources. A symbolic struggle is being waged against the pharmaceutical sector. This is not a good sign. A number of measures will not be appreciated by the pharmaceutical industry. He further points out that the debate on health care must be taken seriously. The speaker also points out that his group is not supportive of a privatization of health care as some suggest.

The Minister believes that the debate on regionalization hides another, on privatization this time. This would be the case in both the south and the north of the country. The Minister opposes regionalization for this reason.

Ms. Avontroodt also does not agree to Mr. Mr. Bottom on the line of denunciation of doctors whose prescriptions are excessive. However, the bill under consideration also contains a number of measures that involve costs. Drug policy is now a legitimate concern, especially at the international level. The Belgian pharmaceutical sector plays an important role in the areas of innovation, employment and economic growth. The Minister has a responsibility to take this into account when making certain decisions.

The member believes that the risk today is to lead to two-speed health care; an evolution that the bill under consideration allows to limit, or even reduce. However, one essential tool for managing the budget is lacking: data.

The bill in the draft is also silent with regard to the moderator ticket. Free health care is not acceptable.

Finally, Ms. Avondtroodt points out that it is high time to develop a regulation on medical liability.

by Mr. Nollet notes that the project contains a number of very disparate provisions. Another chapter focuses on the accountability of the different partners. Ecolo also subscribes to the proposed regulations. The chapter on medicines proposes a Kiwi model suitable for Belgium. The intervener does not see these measures as an offensive against the pharmaceutical industry.

With regard to the chapter on power delegations, the member subscribes to the final objective of the project. It must be possible to intervene in the short term. However, the proposed method is not the right one. The text is too loose and multiplies power delegations, which will ⁇ not make the system transparent.

by Mr. Verhaegen notes that no real answer has yet been given to the question of organizing hearings.

by Mr. Mayeur highlights the rather paradoxical context surrounding the bill under consideration. Despite the growth in the healthcare budget (+4.5% in the government agreement), it still seems limited as costs and demand for healthcare are constantly changing. Therefore, the government should take measures, even exceptional, to try to control the evolution of costs and expenditure in this sector. However, these should not shut down access to health care.

The speaker is also of the opinion that a debate should be held around the problem of setting the growth standard.

In the case of medicines, Mr. Mayeur believes that accreditation measures encourage rational prescription of medicines and participate in the logic of responsible actors.

With regard to the changes made to the Hospital Act, the idea of zone-based care and programming pools appears to be an adequate way to streamline the medical supply in the different regions and sub-regions of the country.

The introduction of pathology packages enables collaboration between hospital sectors and constitutes a more coherent and cost-effective approach to hospital management. This system does not decrease the quality of the offer made to the patient.

Article 29 of the draft sets out the general principle that it is forbidden to request additional flat-rate contribution from the patient who appears in an emergency care unit. Thus, limiting the use of emergencies by imposing this flat-rate contribution on patients is neither an adequate measure nor an efficient measure and alternative measures must be encouraged.

In addition, Mr. Mayeur fears that the moratorium on hospital charges on medical fees creates management problems for hospitals.

Regarding the medical policy, Mr. Mayeur believes that the introduction of a tender system is a rational approach generating savings. by Mr. Mayeur is pleased that, when a heavy "pirate" equipment is operated in a care institution, the bill provides that this institution can be sanctioned during an intervention of INAMI inspector physicians. He is also pleased that the bill definitively sets the programming of RMN and PET scanners.

by Mr. Drèze is attached to Article 21 of the project on hospital associations, which provides that, if a hospital association is operated by a legal person, the latter may have as members or associates only legal persons who operate the hospitals directly involved in the association.

Just like Mr. The Mayor, Mr. Drèze is against the introduction of an additional flat-rate contribution for patients who appear in an emergency care unit.

With regard to the freezing of retentions on medical fees in hospitals, scheduled for one year, the interviewer asks the minister to clarify what happens for hospitals that operate on the basis of actual costs. Will they be able to continue operating on the basis of an agreement based on actual costs?

Ms. Detiège recalls that spending on medicines accounts for about half of the current budget surpluses in the healthcare sector. This finding now leads the chairman of the sp.a-spirit group to propose the use of the New Zealand model. The speaker welcomes that the principle of public procurement is included in the bill under consideration. Ms. Detiège is of the opinion that it would be useful for the Minister to carry out, after a year, an assessment of the functioning of the established public procurement system.

Finally, while the arrival of generic medicines has undoubtedly stimulated the fall in the price of medicines, the interviewer also points out that some original medicines may, today, be cheaper than generics.

The Minister acknowledges, like Ms. Detiège, that a drug that has won a public procurement will benefit from a better rate of reimbursement and will ⁇ be more demanded by the patient. This medication will therefore benefit from a certain relative advantage over other medicines. This is the price to be paid by the tender system. This is the paradox of a liberal economy, where the most effective company takes over the market and can even get a proposal for monopoly on the market.

The bidding system will also allow certain pharmaceutical firms to obtain a more comfortable position on the market for older molecules. In 2004, medicines accounted for 50% of the healthcare budget deficit, while they accounted for 17% of the overall spending mass in the healthcare budget. In any case, public procurement will be organized for all generic and branded medicines.

As for the moratorium on medical fees, it is a moratorium in relative value and the fixed rate of collection cannot be exceeded, even if the hospital's turnover grows because the number of patients increases.

With eight votes against five, the committee decided not to conduct the hearing.

I am pleased with the arrival of Mr. Goutry who, I’m sure, will join me, to thank the services who worked in quite exceptional conditions and for the quality of the work provided. I would like to conclude my report by thanking them very sincerely.

Madam, you shared the work and you were afraid of not "holding" until Mr. Arrives. Goutry, but you did it with a lot of talent.

Mr. Goutry, you should therefore not continue on Mrs. Burgeon’s timeline. As a co-reporter, you are now given the word for your report, and I have understood that you are later, after entering a nice cesuur, intervening on behalf of your group.

Mr. Speaker, Mr. Minister, Colleagues, that Mrs. Burgeon, my fellow rapporteur, what took time is evident because it was a serious workwork on which we may have spent a total of ⁇ twelve hours. The issuance of a report worthy of this Parliament must be proportionally proportionate.

Colleagues, I would of course also like to thank the services for the cooperation in difficult circumstances caused by the MPs of the majority who came late with their case and especially very late submitted their amendments, which naturally caused a delay, which was also at the detriment of the staff of the departments concerned. We thank them because the report, after making the necessary corrections to which we have also helped, in any case proved to be a serious workpiece.

As agreed, I will continue the article-based discussion. As regards Article 2, Mr Goutry noted that the Special Solidarity Fund was established to cover the costs of health disorders, rare diseases and exceptional benefits for which intervention has not been provided for in the compulsory insurance. The Minister has clarified that in 2004, 12.4 million euros were allocated in the budget for the Special Solidarity Fund. I have responded that, however, 15 million has already been spent despite the budgeting of 12 million. The Minister responded that it would be based on the figures of the budget.

Then Mr Goutry noted that the proposed article quinquies stipulates that the age of the children, who can automatically resort to the Special Solidarity Fund, is raised from 16 to 19 years. Finally, on a question from a number of commissioners, including colleague Bultinck, the Minister answered that he did not have the figures of the expenditure for children up to 16 years.

In May 2003, a guide was prepared to inform people about the existence and functioning of the Special Solidarity Fund. A number of committee members have asked the Minister whether that manual should be renewed, which the Minister confirmed.

I have submitted an amendment no. 2 submitted which aims to ensure that the system of the Special Solidarity Fund remains residuair and that the Fund intervenes only where the mandatory insurance does not provide intervention.

Mr Drèze has an amendment no. 49 submitted with a view to avoiding double payments under the Special Solidarity Fund and any other supplementary insurance. Their

I have also submitted an amendment. 1 submitted to make a technical improvement, with which the committee could agree unanimously.

Article 2 was subsequently amended. 3 submitted by me and Mr. Verhaegen, which aims to add the words "or a part" in the third paragraph of the draft article 25, of which Article 2 is of course concerned. The purpose of the amendment is to make it possible that the part of the costs incurred but not covered by the compulsory insurance could also be covered by the Special Solidarity Fund.

The Minister did not agree with this amendment and was therefore rejected.

Mrs Avontroodt delivered a presentation in which she said that it cannot be prevented that a vital medication is only partially refunded. The philosophy of the Special Solidarity Fund should therefore not be disrupted.

Amendment No. 2 was also introduced. 4 I and my colleagues submitted. The aim was to avoid double payments. I warn my colleagues, as in the committee meeting, that this could be the case. However, the Minister says he will not agree because he thinks the text is clear enough.

We submitted an amendment no. 5 in, where we proposed to repeal point b, namely that it could not be medicines that are still in the experimental stage. We added that in the case of rare diseases it is almost obvious that it will also be experimental medicines. The Minister did not agree with this and the amendment was rejected.

Amendment No. 6 was subsequently submitted by me and Mr. Verhaegen to clarify a wording in the text. The Minister provided an explanation which satisfied the applicants of the amendment, since the amendment no. 6 was subsequently withdrawn by the gentlemen Verhaegen and Goutry.

Amendment No. 7 of me and Mr. Verhaegen serves to make the text more clear and also to bring in conformity with the French-language text. The Minister agreed with this technical amendment.

The Minister cannot agree to the amendment no. 5 which we have submitted, nor with amendment no. 8 which again extends to allowing the experimental medicines to be reimbursed.

We have submitted an amendment, amendment no. 9 of me and Mr. Verhaegen, to replace the word "allocations" with the word "indications". The Minister has proposed not to accept that amendment, which the committee has not done. I have submitted amendment no. 9 withdrawn, after I had heard the explanation of the Minister.

Amendment No. 10 of me and Mr. Verhaegen went for a text improvement and the minister fully agreed with it. The committee approved the amendment. Amendment No. 11 of me and of colleague Verhaegen sought to preserve the coherence of the text. The Minister agreed and the amendment was adopted. Then in the committee a score was determined for the number of adopted amendments from the opposition, and the stand was six-zero.

Amendment No. 12 of the gentlemen Goutry and Verhaegen went for a text improvement. The Minister accepted the amendment.

Amendment No. 13 aimed to replace the word "physician-specialist" with "physician-specialist", as the Council of State also proposed to us. The Minister agreed to the amendment; it was therefore also adopted.

In this article, amendment No. 14 submitted by me and Mr Verhaegen, in which it was intended that the conditions of the Special Solidarity Fund should be cumulatively met. The Minister agrees with that amendment: each of the conditions must be met. Therefore, our amendment No. Article 14 is also adopted.

Amendment No. 15 of myself and Mr. Verhaegen we have pointed out that it is unusual to place legal texts between hooks. The Minister then proposed not to change the text, but to remove the cracks. That was a good compromise and a technical problem from the job. The text was improved. Therefore, we naturally withdrew our amendment.

There was an amendment no. 16 of me myself that was about language correction. The Minister accepted this amendment with the language correction.

Amendment No. 17 of myself and colleague Verhaegen sought to replace the second sentence of the draft article 25octies with the text proposed in the opinion of the Council of State. Strange but true, the purpose of the amendment was to clarify the text. However, the Minister did not agree with this and became the amendment no. 17 voted down later.

Amendment No. 18 of me and Mr. Verhaegen sought to clarify the text. The proposed amendment clarified the wording of the text and was therefore accepted by the Minister and the committee. The stand was 9-0 at the time.

Amendment No. 19 came from Mr. Goutry and Mr. Verhaegen. The Minister acknowledges that this article may not be very clearly formulated, but that the intent is quite clear. The Minister is opposed to the amendment no. 19 is recommended. It was later rejected by the commission.

Then Mr. Goutry proposed that the activity report - article 25decies - which the College of Physicians-Directors annually prepares for the benefit of the Insurance Committee would also be forwarded to the Commissioners, to the members of the Public Health Committee, to study it. The Minister has said that after passing the appropriate channels, the annual report will also be forwarded to the committee, to the Commissioners.

This is how we end up, Mr. Speaker, on Article 3. Article 2 was a very long article. Article 3 was about the retroactivity of the Special Solidarity Fund for children up to 19 years of age. Mrs Avontroodt wanted to know why certain articles are applied retroactively and whether the minister has an idea of the budgetary cost of this. The Minister confirmed that he did not know this cost and Mrs Avontroodt then wondered how the persons concerned could be reached given that it is an article with retroactivity. At the same time, the Minister clarified that a broad information campaign will be organized to inform the people. Our committee chairman, Mr. Mayeur, then pointed out that such cases are known to the social service of the hospitals and can therefore be detected.

The articles 4 to 6, colleagues, deal with the non-inherited brain diseases, say compacients. This will provide for a better arrangement and these people will be able to receive a full refund also for home care due to the heavy, chronic costs. Mrs Avontroodt and other colleagues in the committee of course found this a positive measure, an improvement for a group of chronic patients who are in a difficult situation. The Minister also added, on our question, that there is no deadline for granting the benefit. In other words, as long as a co-patient is cared for at home, he can resort to this accommodation.

In Articles 7 and 8, I myself pointed out that the article aims to promote the rational prescription of medicinal products. The Minister stated that the proposed provisions should enable pressure to be exercised on the national committee for doctors-hospitals funds. If there is no result by summer, the Minister can take the necessary measures on the basis of the law itself. Our colleague Drèze asked questions about the effectiveness of the measure envisaged.

I myself then reminded that the previous Programme Act of 2002 already contained sufficient measures to individually responsibility the healthcare providers. We asked why it was not used.

Ms. A. D. has submitted the amendment no. 58 in, which aims to supplement the proposed provision. The amendment is approved.

He submitted the amendment no. 73 in the same subject as amendment n. and 58. Therefore, of course, this was also adopted.

Mr Verhaegen and I submitted the amendment no. 20 in order to make technical improvements. The Minister approved this technical improvement.

I am referring to Article 8a of the Health Act. Article 8a is a new article. It is about the statistical data related to reimbursable pharmaceutical specialties and its transmission to the profile committees.

Mr Verhaegen and I submitted the amendment n. 21 in order to remove the prohibition on the provision of the data to the profile committees, which would be the logic itself. Unfortunately, Mr Barzin, the committee did not accept the amendment.

Articles 9 and 10 refer to the reference amount of the hospitals. Article 9 provides that recovery shall take place from 1 January 2005 if the reference amount is exceeded. We noted that this will not work as long as there is no unique patient number per patient.

The Minister noted that no hospital has so far been penalized for exceeding the reference amount. Therefore, he wanted to make the improvement here in Article 10.

President Mayeur supported the measure, which is coherent as far as a homogeneous patient group across hospitals is concerned. The Minister acknowledged the need to modulate the reference amount, taking into account various variables, in particular on the medical and social level.

Mr Drèze noted in Articles 9 and 10 that the purpose of the reference amounts is to limit any flat-rate amounts to 16 pathologies. He asked if it was intended to continue.

I myself argued that we are not against the principle, provided, however, that it is workable. In our view, Article 56ter is not actually applied, as it is formulated, and the proposed provision aims to provide for greater rigor in relation to the excesses. Otherwise, the provision threatens to be ineffective again.

Mrs Avontroodt would indeed find it unfair if the excesses were only recovered on the doctor’s fees. Ms. De Meyer is in favor of the future fixing of the flat-rate amounts that will only increase transparency for patients.

Articles 11 and 12, President, colleagues, dear colleague Mrs. Barzin, deals with heavy medical equipment. These provisions relate to health insurance for benefits using heavy medical equipment. Amendments 50 and 51 were submitted by Mr Drèze. This is about the programming criteria that should take into account a better geographical spread. Finally, Mr Drèze concluded that the Minister confirms that in all regions the norm is exceeded because it is considered to be inadequate for medical reasons. Ms Dierickx added that it would not be logical that if the healthcare provider used such a device extra muros on an outpatient basis and the patient was informed of it in advance, that provision would not give rise to a benefit due to the RIZIV.

I myself made an observation in which we believe that the proposed provision actually constitutes a hereditary federalization of a community competence. The Minister opposes that this would be a re-federalization of a community competence. Mrs Tilmans has concerns about the geographical distribution of the PET scans and asks the Minister whether the programming takes into account the distance between the hospitals, say the geographical criterion. I am already on page 66 of the report, for the colleagues who follow. Still on Article 12, Amendment 59 was submitted by colleagues Goutry and Verhaegen, which provided for a technical improvement.

I am referring to Article 13. I myself have argued that the proposed Article 13 concerns the appointment of a full-time delegate who will be charged with the organization and coordination of the health insurance policy. The President and I have amendment no. 40 submitted to delete the article, for not realizing the usefulness of the appointment of such quality officer. In addition, we have amendment no. 22 submitted in the sense that if the majority would still decide to appoint such a deputy, it would at least be avoided that this becomes a political appointment and that Selor should organize the assessment.

We have amendment no. 24 submitted, together with Mr. Verhaegen, in which it was intended to better formulate the article in the sense of the renewability of the mandate after 6 years.

We also have amendment no. 25 submitted on the composition of the Steering Committee to be added to the Special Representative which will now be provided by this Article. Mr Bultinck has submitted amendment no. 46 submitted to dismiss the draft provision, but the amendment was not accepted by the committee. Their

I am referring to Article 13a. The President and I have an amendment. 39 submitted, with which we want to install a delegate who is full-time in charge of managing the data that all exist within Public Health and the RIZIV.

Finally, Mr Verhaegen pointed out that objective selection is provided for for less important functions and that therefore it cannot be justified that no objective selection is made for the delegate for quality control and the measures provided for in Article 13.

I came to page 72 of the report. Article 14 did not give rise to any special comments. As regards Article 15, I have, together with Mr. Verhaegen, submitted an amendment no. 64 submitted to remove this article due to double use. However, the Commission did not intervene on this. Article 16 relating to the reduction of the legal procedures in the RIZIV is an improvement and therefore did not give rise to any special comments.

There was an amendment by Ms. De Meyer aimed at inserting an article 16bis aiming to fix a maximum amount for implants and medical devices. Mr Drèze emphasized that it was about its pricing and the determination of a maximum price, that this is a competence of the Minister of Economic Affairs and that therefore there is no point in providing this here. The Minister points out that, however, it is not an economic aspect but an aspect of the protection of the patient and claims this competence itself.

Mr. Verhaegen and I have sub-amendment no. 86 submitted to amendment no. 67 in which we argue that if it is such an important matter – of which we are, by the way, convinced – this must be arranged in a proper manner and it would be better that it applies as soon as possible, in particular on 1 January 2006.

We have also pointed out that Article 16bis, which was a consequence of Mrs. De Meyer’s amendment, was technically inadequate and that this article, which is included in the bill and was adopted in the committee, crumbles on all sides.

The has asked Vandeurzen where the definition given to an implantable device comes from. The Minister gave an explanation on this.

A new article 16b was added as a result of amendment no. 67 of Mrs. De Meyer, in which she proposes that Article 16bis enter into force on a date to be determined by the King. We have a sub-amendment no. 86 submitted to fix that date on 1 January 2006.

I have arrived on page 79 of the report. It is going well forward. With regard to Article 17, I have myself reminded that the principle of care regions does not affect the CD&V group at all and that we absolutely do not realize the usefulness of such care regions. These will only cause complications on an organisational level, they are, by the way, not compatible with the Flemish care regions and will only lead to a centralistic, from above imposed policy on cooperation between hospitals and institutions. In the past, it has been shown that this does not work. The President and I have an amendment. 29 submitted which aims to remove Article 17 concerning the care regions. Mr. Bultinck also raised intrusive questions in this regard, not least regarding the application of the principle of care regions across the two Communities.

I arrived on page 86. Mr Vandeurzen asked a question on the scope of Article 17. The Minister has responded to this. On Mr Vandeurzen’s first question, the Minister recalled that the government first wants to meet the needs of the people and that this is the purpose of the text approved by the committee.

Articles 17bis to 17septies regulate the statute of public and private hospitals. Amendment No. 87 of Mr Vandeurzen sought to ⁇ an equalization between the statutes of the staff of private and public hospitals. This amendment has been discussed extensively. The Minister has confirmed that he knows the situation as explained by the applicant of the amendment. However, the Government did not accept this amendment. The committee did not approve the amendment.

Article 18 of 18. Mr Drèze has amendment no. 53 submitted with a view to removing Article 18. This amendment was not approved.

Articles 19 and 20 address the programming criteria related to the healthcare regions. A broad discussion was devoted to these articles. You can find a reflection of this in the report up to page 92.

Article 22a of the Treaty. Mr Mayeur submitted amendment no. 68 In that regard, Article 22bis is intended to be introduced. This amendment aims to add a chapter of the Hospital Act concerning programming and recognition as regards the implementation of multiple establishments.

Article 22a of the Treaty. This new article was added through Mr. Mayeur’s amendment. This article was approved by the committee.

Article 23 did not give rise to any special comments.

Article 24 deals with the special contribution that can be requested in emergency services. With this article I have arrived on page 95 of the report, which is being followed by you with a crushing attention!

No comments were made on Article 25.

On Article 26 I have amendment no. 31 submitted with a view to obtaining the opinion of the multipartite structure before the King’s decision.

On Article 27, Mr Bacquelaine submitted amendment no. 71 in which it is pledged to exclude the period of the night from the contribution. In this regard, I and my colleagues have submitted amendment no. 41 submitted in which we propose to apply the contribution due to improper use that the emergency services may request, day and night. We do not see the logic in why this contribution would not be requested at night.

Mr. Goutry, a foreign proverb says “la nuit porte conseil”. It is normal to sleep at night. Therefore, la nuit porte conseil.

And you complain about it in the morning, Mr. President.

Mr Verhaegen and I submit amendment no. 32 in The Minister agreed to this because it is a technical improvement. No comments were made on Article 28.

I am referring to Article 28a. This is an important new article that was proposed by Mr. Verhaegen and myself. This article seeks to introduce the impossibility of charging fees supplements on two and multiple rooms.

Mrs De Meyer agreed to the substantial importance of that amendment, but said that it was too early to make a positive decision. Ultimately, the amendment on the limitation of supplements was not approved by the committee.

Article 29 was requested for discussion, but no amendments were made. Regarding Article 29bis, a new article, Mr. Drèze pointed out the importance of supporting care for children with cancer, who stay at home, by Liaison teams.

I come to Article 30, on page 102 of the report. Amendment No. 34 submitted by myself and by Mr. Verhaegen. It aims at a technical correction. The Committee unanimously accepted this amendment.

With regard to Article 31, Mr Drèze believes that the evolution of the medical need makes it undesirable to reduce the number of PET scanners in our country. Mr. Ducarme has said that he acknowledges the importance of limiting the number of PET scanners, but he questions the criteria included in the bill and especially the actual control of the control of related expenditure. Finally, I have stated myself that the Minister could impose sanctions under Article 11 of the draft. This means that if institutions continue to violate the standards in the future and therefore illegally use PET scans, the minister could order them to close them with a hard hand and immediately.

Articles 32 and 33 did not give rise to debate. Article 34 was discussed, but there were no amendments. No comments were made on Articles 35 to 43 on page 104 of the report. To Article 44 there is an amendment by Mr. Goutry. This is amendment No. 62 to make corrections in the Dutch text. This was confirmed and approved by the committee.

In Article 45 there is the amendment no. 60 of the gentlemen Verhaegen and Goutry to bring the texts in alignment with the French text. This amendment was accepted. The stand was 13-0 in favor of the opposition.

There were no special comments on Articles 46, 47, 48, 49 and 50. On Article 51, on page 105 of our report, there was the amendment no. 61 for me and my colleagues. The committee agreed.

There were no comments on Articles 52 and 53. As you have very well noted, Mr. Speaker, the stand was then 14-0. This can be added to this report.

Article 54 was about the famous authority. There was, of course, a long discussion on this. In that context, I refer to the report, in which, on many pages, the very in-depth debate has been presented, on the opportunity and the technique of mandates. This is on page 114. Mr. Verhaegen gave an extensive presentation on this subject, focusing primarily on institutional ice. He cited the Constitution and demonstrated in a glass-clear one-hour speech that powers can only be taken in exceptional circumstances, as determined in the State Council opinion. He has fully proved this advice in all his finesses.

There was the amendment no. 74 of Mrs Avontroodt to replace the word "honoraria" with "the amounts that serve as the basis for the calculation of the insurance contribution". The amendment was unanimously adopted. There was also an amendment 74 by Ms. Avontroodt with the same scope, which was also unanimously adopted.

Mr Drèze gave explanations in his amendment no. 55, which aims to abolish Article 54. Mrs. De Meyer said at the time that it is not a matter of special powers, as it was in the past, and that the minister merely asks the power of Parliament to take measures until December 2006.

Mrs. D'Hondt, you want the word?

Mr D'hondt, of course, I must maintain the objectivity of the report, but the report is followed by my presentation.

You do not mean that you will not be objective in your argument after the report?

I will, of course, be completely objective. Objectivity is characteristic of CD&V. Colleague D'Hondt, I am currently on pages 108, 109 and 110. In it is detailed the explanation of Mrs De Meyer.

I myself have continued to reflect on some of the 14 points for which the King may impose austerity measures according to the old article 54 — now re-numbered to article 58 .

Mr. Verhaegen and myself also found that the 14 points were too vague. Mr Verhaegen referred to his argument on the opinion on the power of the State Council and concluded that the conditions to which the State Council had subjected the article were not met.

Amendment No. 63 Mr. Verhaegen and myself proposed to remove Article 54 in connection with the mandate because it is completely unnecessary, useless and in the current context unreasonable.

Article 54bis is a new article submitted by Mr Vandeurzen by amendment no. 93 and that aims to establish a permanent committee for the examination of the nomenclature. After an extensive discussion and an amendment by Mr Verhaegen and myself on the third-payer scheme, the Minister did not accept the amendment on the third-payer scheme. The Minister proposed that the committee accept the amendment of Mr Vandeurzen for the establishment of a permanent committee for the re-alignment of the nomenclature.

In Article 55, Mrs Avontroodt proposes, by amendment 75, to replace the article. It is a key article that deals with the very complex context of the group-specific reviews of medicinal products and the market surveillance of medicinal products. It was replaced in plenary session with an amendment by Mrs Avontroodt completely by a new article. We pointed out that by the amendment the kiwi was exhausted, leaving only a dry fig. We also emphasized that the members of the majority have made a 180° curve from what they had initially announced.

Amendment No. 75 ...

Which article are you talking about?

I am now on pages 119 and 120. I am still talking about Article 55.

I myself have found that the explanatory note to Article 55 shows that an agreement was concluded with the pharmaceutical companies. If the law is amended, they will partly contribute to filling the treasury. I said in the committee then that the agreement was clearly sold by Mr Stevaert. That literal quote is on page 120.

Article 56 concerned generic medicines. Ms. Avontroodt has on this article amendment no. 76 submitted that the entire, old article 56 was replaced by a new article.

Mr. Speaker, little detail: it was already around two o’clock in the morning.

I came to page 122 of the report. Mr Drèze has — which will have been at five o’clock at two in the early morning — amendment n. 56, which seeks to replace in Article 35ter the words "thirty percent" with the words "fourteen percent".

Article 56a allows exceptions for generic medicinal products. This article was amended by amendment no. 71 submitted by Ms. Avontroodt, which introduces Article 35quater in the same law and which could exclude from the review a number of substances showing special therapeutic qualities.

I am referring to Article 57 on blz. 124 of the report on the important health law. Mr Mayeur has on this article amendment no. 78 was submitted. We found that, if we had understood the amendment correctly, it would be a "disconnection" of the public price to the reference price for refund. We have pointed out that this technique is not without danger and is not very coherent with the technique used in the previous articles, which specifically calls for a price reduction. On the other hand, with the aforementioned amendment, it may be possible to decide on a price increase.

Article 57bis is a new article, which was introduced by amendment no. 79 of Mrs. Detiège. It proposes that the committee should draw up an annual report on the analyses it carries out in accordance with the article, namely the studies on which products may be eligible for revision. I have asked myself whether the Committee on Medicines will find the time to undertake this great work. Ms. Detiège referred to her previous experience and said that this would not be a problem.

Article 58 on page 126 was discussed, but not amended.

An amendment to Article 59 was submitted by Ms. Detiège. Colleagues, you will notice that as the session progressed and the articles postponed and gained interest, more and more amendments came from the majority. On Article 59, Ms. Detiège has amendment no. 95 was submitted. Amendment No. 80 was withdrawn because it was misformulated.

Finally, there was the Amendment by Ms. De Meyer aimed at replacing Article 60. The amendment concerned the fact that pharmaceutical companies would be given some time margin in order to get a certain time spread for their clawback — in Dutch the refund of the excessive amounts spent on medicines.

Article 60a is a new article. Ladies and gentlemen, it was already about three o’clock at night. You can note that Mrs. De Meyer was still very active in the committee at the time. Mr. Speaker, at four o’clock before three o’clock at night, she submitted one amendment after another. Furthermore, Mrs. D'Hondt, Mrs. De Meyer worked hard to explain all of her amendments in detail.

The attention was not equally sharp among all members.

Amendment No. 82 submitted, to introduce a new Article 60a. At 2:45 p.m. at night, it was simply about a tax of 23 million euros – ⁇ 10 billion old Belgian francs – in compensation for the pharmaceutical industry, in order to purchase the measure through which the advertisements on medicines were mitigated.

Article 61 refers to large packaging that should be 20% cheaper and did not give rise to any amendments.

At three o’clock, when the kiwi had long become a dry fig, the services of the Chamber still diligently supplied us with the necessary drinks without suffocating, while many committee members had already done so.

Mr. Goutry, we saved you a second night session in the plenary session.

That is true, for which you may thank.

There may also be jealous wives, my dear consoler.

Per ⁇ we will now go back to a night session, Mr. President.

On Article 61bis, Ms. Detiège made an amendment no. 3 at 3 p.m. 83 submitted with a view to bringing medicinal products over the age of 15 years into the system of price reduction.

Ten minutes later, Mrs. De Meyer submitted amendment no. 84 in Article 62. Our chairman, Mr. Mayeur, was still in shape at the time, but from time to time clearly showed that it was working on his nerves. However, he granted Mrs De Meyer the floor for amendment no. 3:10. 84 to submit on the implantable devices. This was not a small amendment that gave rise to discussion. I quote what was pronounced at 3:15 am: “The ban is also justified for ethical reasons as evidenced by the commotion about the advertising of breast implants and in particular about an internet advertising for Easter breasts.” I repeat: “Easter breasts”, des seins de Pâques! This is on page 129. Mrs. De Meyer spoke there about a company that was considered to promise candidates free Easter breasts if they would show themselves topless on the website. This discussion gave rise to some hilarity leading to the time of 03.30 am. At that moment, many colleagues woke up again.

Article 62bis is a new article by Mrs. De Meyer who had found her fourth breath.

I would like to remind the reporter of a strange fact. We were offered a small snack by the services. We got a waffle that we had to eat quickly because the next day the date had expired.

We had to eat it quickly because otherwise the Public Health Commission would have been hit by expired waffles.

The durability of the waffles posed a problem.

Yes, the expiration date had almost expired.

Mrs. De Block, you also want to interrupt for a personal fact?

I would only say that I am pleased that Mrs. De Meyer has noted this as questor, because she is in the right place to do something about it. We have experienced this here before.

I have been here for 13 years. I only note that during the previous governments, where I was also part of the majority in Parliament, we never had problems with the expiration dates, but the latter governments work so slowly that the expiration dates of the yoghurt and the waffles in the buffets expire.

Moreover, the durability of the "passover breasts" has not been discussed.

I will have to act as a moral master if it continues like this. Mr. Goutry, you can decide on your report if you wish.

I am on the first page, page number 129. A new Article 62a has given rise to discussions, but not to amendments.

Article 63 has also been discussed, but not amended.

Finally, colleagues — which would have been long after 3:30 p.m. — Mrs. Avontroodt had the exhausted courage to submit another amendment, to the great joy of the Chairman, who was very angry about it in the sight of the whole committee. This was the amendment no. 72 concerning the transitional measure for the depositing physicians.

Colleagues, Mr. Speaker, Mr. Minister, in the end, the report was drawn up in good cooperation with the co-rapporteur, my good colleague, Mrs. Burgeon. Thank you for the smooth cooperation, Mrs. Burgeon.

Finally, the bill was voted after a second reading of the text. There was also a reading of the report. In the end, the entire draft law was finally approved with 10 votes for against 3 abstentions.

Thank you for your comprehensive and objective reporting. I know that you have asked for the word to speak now on behalf of your group. I will ask Jean-Marc Delizée to want to replace me here, because I have a Conference of Presidents. I wish you a good pace in your intervention on behalf of your group.

You have the word on behalf of your group, Mr. Goutry. President: Jean-Marc Delizée, First Vice-President President: Jean-Marc Delizée, Prime Minister and Vice-President.

I may have a small correction. The draft was approved with 11 votes for, 1 against and 3 abstentions. There have been several moods and I lost the thread for a while, for which I apologize. Thank you colleague rapporteur.

Mr. Speaker, Mr. Minister, colleagues, I am switching from the report to a substantive and political reasoning, on behalf of our group, to assess the proposed draft, namely the famous Health Act.

Colleagues, I have a previous general consideration about the way of working. Please do not apologize that I am still formulating this concern. After all, it is gradually becoming a custom, we are very unhappy about it, that bills, especially in the Committee on Public Health, are submitted late, then lead to a more or less forced treatment, under time pressure, in which, in general, one is not listening properly to each other, in which one falls into the classic contradictions between majority and opposition, and in which the essence, the content of the draft threatens to be compromised.

However, colleagues, the Health Act is an important project. We did not understand it well. This project was announced, with texts. We have also received this much in advance. There is no problem there. We have also been able to work on this during two committee meetings.

Suddenly, and I would like to repeat for a moment that this was the great annoyance of the opposition, the colleagues of the majority at the third and last committee session came to the streets with about 20 amendments. These amendments rewrite the texts very thoroughly. Even full articles were removed. We received these amendments during the session. We have requested a temporary suspension in order to allow the opposition to get acquainted with the content of those amendments, in order to also be able to consult the people that we consider useful for this. There is no desire to intervene in this. This resulted in a very long marathon session. Mr. Speaker, Mr. Minister, although it has gone well, this session may have been a little bit compromised in quality. At three o’clock in the night, however, one does not do as good work as at three o’clock in the afternoon.

As a result, many mistakes have been made. From the opposition, I would like to emphasize that, we have cooperated constructively. We have adopted 17 amendments, technical improvements. These were more than technical improvements, because amendments were needed. We have also updated the texts. We have worked together to improve texts and so on.

Ladies and gentlemen, then there was another blow to the firepile. At the time when the project was brought here to be presented in the plenary session, that was the Thursday before the Easter holiday, it turned out that there was an error in the design. We had noticed this and also signaled it.

The majority was a little panicked. It was determined that the third point of the mandate had been amended. Therefore, one agreed to say that it was a knot bull, that one would no longer treat it for the Easter vacation and that one would postpone it until after the recess. This is why we stand on the floor today to comment on this law. The result of this is unfortunately that there is no good atmosphere. It is an important design in which we could exchange many important things with each other. The result is that it is not a good law. After all, it is a law with many improvements, with many corrections, with a lot of art and flight work. We are always very reluctant in this regard. We are always faced with a lot of reservations.

Per ⁇ the most important thing is the following. It is a law that for many provisions had to come into force on 1 April. The legislation will be voted on late. It is now 13 April, the law has yet to go to the Senate and it has yet to be published in the Staatsblatt. The law had to come into effect on 1 April. The government will be happy if the law comes into force on 1 May.

So the Minister has immediately missed an important month, which he had yet marked with his draft. Until then, my colleagues, the general concerns.

I now come to the various points that I briefly discuss and on which I express our opinion. First, on the Special Solidarity Fund, colleagues. We fully support this, Mr. Minister. This is an important pillar of health insurance. In addition to the mandatory insurance and in addition to the maximum invoice, we actually have more and more a kind of third pillar. Finally, it is already about 1 billion Belgian francs that we are spending on it. Indeed, the Special Solidarity Fund provides assistance to a large number of people, especially in situations where, for example, they are the prey of very expensive treatments, rare treatments often also, in rare diseases where, precisely because of the rarity, there is still no insurance coverage. For these people, the Special Solidarity Fund represents a very important aid. The sum also speaks for itself, 1 billion Belgian francs is distributed to people in need. We support the improvements that have been made. We think this is a good article. We could also have approved a number of technical amendments that will definitely improve the article.

I have a concern, Mr. Minister. We will come back to it later and ask questions about it. We have asked you how much has already been spent in the Special Solidarity Fund. You said it was 12 million. We said it was 15 million. You said that your figure was the estimate. We said that our figure was effective what was spent. Then the discussion is actually over. However, I would like to take this again to say that last year already spent 3 million more than originally planned. You have now raised it to 22 million. Therefore, we argue that it will be too little. After all, you have expanded it and you have a deficit from last year, which you have not calculated. So our advice is to take that shortage with you and make sure you have a realistic budget, to avoid those facing rare conditions and with expensive treatments being unable to get care.

The second point of the draft, which we also support, is the scheme for the compatients. This is an important and good arrangement by which for very severe chronic patients who are being cared for at home, a compensation for all costs of home care will be introduced. We have of course supported this.

A third part of the law concerns the rational prescribing behavior of doctors. With this, we already have some more problems. Not with the principle, because it is clear, obvious and it should be obvious that doctors rationally prescribe, that they prescribe price and cost consciously. There are no doubt many doctors who do that too. We are also convinced of this. Only we still lack the right means or instruments to map this too. In fact, we have those means – I think of Farmanet – but there is no political courage to make a clear, good overview, a picture, of the prescribing behavior of the doctors and to clearly use it as an educational and controling instrument towards the doctors, such that they also see how it is with their prescribing behavior. Now it is more about punishment in the law. The Minister announces an investigation — apparently so it is possible — to find out who prescribes irresponsibly, after which the accreditation is withdrawn and a financial penalty is imposed. Well, we are of the opinion that this is the reverse world. In fact, we should have punished the people who make too many prescriptions for a long time, because this is precisely what the Responsibility Act has served.

In fact, an article should be included in the law to give a positive incentive to doctors who prescribe well, by rewarding doctors who do their best, rather than punishing some for their prescribing behavior. We do not need the law for that; we could already do it.

I would just like to say to our excellent colleague, Mr. Goutry, that we are not in front of two systems of the same nature. The first system, which calls for accountability, must identify a number of behaviors in the field of prescription.

Here, we are talking about something much more specific, namely accreditation. This is not a sanction against doctors. What is it about? The mechanism of accreditation is as follows: a doctor follows a training allowing him to prescribe in a logic of health economy which should be concretized by a behavior, ⁇ prescribing the best medicine, dear colleague Goutry, but also respecting this logic of health economy according to which it should not cost too much.

Mutualities have helped us to find that those who receive a supplement of compensation, therefore more financial means, have the same behavior as those who have not followed the training. We conclude that it is illogical to pay them more and we don’t do it anymore. Therefore, it is not really a penalty in the sense of accountability that you are talking about; it is not about not granting additional compensation to those who do not change their prescription behavior.

I wanted to make that clarification. This does not stop your reflection that we must be aware that there are now accountability mechanisms and that they must work.

I read it in the medical journals of the doctors. They are very opposed to the measure. That is exactly what you better not get as a result. If you take measures to responsabilise certain groups, then you must get those groups with you, otherwise you can’t responsabilize them and you find yourself in a repressive story in the sense of “we will take you and take away your accreditation”.

They ask to make a positive story of it. That’s why I said we have a responsibility law. It says there may be outlayers, excess prescribers. They can be punished. It also states how this can happen. The law should only be enforced, not through accreditation, but in a much more interesting way, namely by reimbursement of what they have prescribed too much. Here they put a stick behind the door that escapes many doctors, myself too. I think the tone has been completely missed.

Furthermore, Mr. Minister, I have many questions regarding the operation of this measure. As you write in your article, it’s about the fact that profile committees will have to act here. Well, you know — we have submitted an amendment — that the profile committees still do not have access to the statistics on medicines. There is still no link between Farmanet and the profile committees. What hell are we doing? This is a false operation, another step in the responsibility process, in which the government occasionally approves an article to have a legal basis, without making the overall context and overall application, namely the link between Farmanet and the profile committees.

Another part of the Health Act, colleagues, was the same price for the same treatment. This sounds like evidence, of course. It is about the so-called reference price, which will be fixed for the treatments. This includes everything that has to do with treatment. One makes a national average of it and one looks at who remains within the margin. This is of course interesting.

I will immediately conclude the fifth point, namely the all-in prices for the hospitals. These are interesting things. These are thought paths that go, as we have always suggested, to pathology financing. These are thought paths that go towards standardizing, based on good medical guidelines, the treatments to be performed for certain diseases, so that they happen in the same way and so that, for example, an appendix surgery costs as much in Brussels as in Flanders or Wallonia. That is the logica zelve. Only we say that again we have great doubts about the practical application of this article, because it is not always possible to ventilate the cost per patient. The principle of "the same price for the same treatment" can only be applied when one can charge all the costs of the treatment of a patient. Today, this cannot be done, because the performance can be distributed. It can be an amalgam of both outpatient, outpatient and intramural performance. This will not be found in the various statistics. They do not refer to the same person. You will not be able to get a link to the same treatment. In other words, it’s nattevingerwerk.

Our chairman, Mr. Vandeurzen, and we, the colleagues from the group, have long been saying that there should be a unique patient file, an electronic file in which all treatments for a patient are immediately accounted for. This makes it possible to clearly see where a patient was staying and what examinations he has undergone. Only then can one, on the basis of statistics, using computer science, take pictures of patients and treatments to determine what has been used for the patient and what treatment has been used for a disease. It can also be checked whether this differs from a national average.

In this way, a real pathology financing could actually be realized. We have noted this. In fact, one has not remained quiet for a long time. They said, “Vote that. We have that article and that is another step forward.” Here, as with rational prescribing behavior, the same remark applies again: one makes constant small steps. Mr. Vandenbroucke has already done it and Mr. Demotte is doing it now: occasionally take small steps legally and provide a basis for things that could be used. However, the entire machine is not assembled to see exactly what that cost control can mean, how the costs can be controlled and how to create clarity and transparency between the spending of different hospitals, of different doctors and also of different regions.

I must not think, Mr. Minister, that there would be cold water fear among the French-speaking colleagues to make that inspection and those sharp photos. I cannot imagine that there would be fear to come out with those photos, because those photos could show a different color in Flanders, Brussels and Wallonia. It would, of course, be dramatically bad if, because of those facts, we would not find the political will and the political courage to continue with an obvious funding in the sense of the same price for the same treatment.

Colleagues, in another part of the Health Act, a quality advisor is appointed. You will be a Superman or a Superwoman. If I read what that person will all have to do, that’s no less! I challenge you to read the article and the texts about it — article 13, I think — which define the assignments of the superwoman or the superman. This is a task that we do not understand. There is such a thing that it is about the coordination of the direction of the evaluation of... By God, we do not know what it could be! In any case, it is dark enough to decide that it will be a political appointment. That will ⁇ be the case, because there is not even a recruitment procedure. The law provides that the King will be able to appoint that high official. Who will it be? Someone who, in the vision of the Minister, will be able to see over all structures, over everyone’s shoulder, how health policy is going, will be able to intervene in it and the Minister will be able to report on it. So that becomes a superman or superwoman on the management of the health budget and who is deadly appointed by the King, without the slightest procedure, without assessment of Selor. If one wants to reach any level in an administration, one must pass at least Selor. Even clerk-typists must pass a test of Selor. What is revealed? That man or woman will be appointed, if any, by the Minister.

I don’t know if the minister agrees with what you say. When I hear this, Mr. Minister, I wonder whether this is consistent with the Copernicus legislation in question. You remember that during the previous legislature, after a public poll with all Belgians, it was said that the top positions in Belgium would be objectivized. Wars of what this has given in reality, there is legislation that from a certain level, as colleague Goutry says, recruitment must be done through assessment procedures. If this is not the case, does this aspect of the design not conflict with other regulations approved here?

Colleague Verherstraeten, that was, by the way, the reason why you also jumped on stage with our support: to ask for the advice of the Council of State. These are things that could not even survive this.

In any case, we have submitted an amendment, first, to abolish that Superman, because we see absolutely no use in that. There are enough official committees. There is a lack of clear will to manage these things. That must be done, not always just shifting and appointing new people, and so on.

In addition, we have a Knowledge Centre. There is all the know-how and that works very well. We can ask anything about policy preparation. We must use that, and not again designate a new person, establish a new steering committee, and so on.

Colleagues, another important element of the Health Act is the fact that the Minister, with the support of his colleagues of the majority, wants to introduce care regions. How should we imagine this? We were surprised when we received the draft law. After all, the minister writes: it must be done for institutions, hospitals or whatever, who do not want to cooperate with each other. We are going from above, centralistically, to determine with whom they must cooperate, compulsorily, independent of any possible ideological or other differences. So, according to the old but failed formula of socialism, the minister says: we are going to direct that centrally. Apparently, one ignores — or maybe one is no longer with in French-speaking Belgium — the Flemish situation where one has long been spontaneously cooperating and one has long been spontaneously starting to scale, but then on the basis of opportunities, on the basis of feeling attracted to each other. This is always the best and most successful way to reach a good cooperation.

The minister now says: the public hospitals have occasionally missed the boat, out of their own unwillingness, and we will force them to cooperate centrally, by region, if necessary.

Even worse, colleagues, those care regions are actually becoming a new programming tool for the hospital world while we had left that track. More and more we abandon the technique of programming. Think of the funding of the hospitals of Minister Vandenbroucke, where one goes away from responsible beds, responsible activities much earlier. Then there is no need for programming because the hospitals respond to the needs. That is, of course, the right debate, a question-driven debate. Now they put that on their heads and they say: if necessary, we will link a programming to that forced geographical concern, to that regional cooperation.

Well, colleagues, one has tried that in Flanders among the greens — it was another invention of Mrs. Vogels, who care regions — tried. We are now three years after date and they are not working. They are being evaluated. They are looking at what they could serve. Imagine yourself .

I have also seen contributions from Mrs. Vienne, the Welsh Minister of Public Health — of the PS, by the way — who says that she does not believe in that at all.

Another part of the Health Act concerns the emergency cases and their improper use, in which the minister takes the fact that the Arbitration Court has destroyed the earlier legislation to prevent the emergency cases from bringing them back into law. In case of improper use, a contribution can be requested from the people.

There is also a measure concerning a moratorium on the honorary salaries of doctors. Mr. Minister, you will have done that to vote the doctors well. You will have done that to close off some kind of pax medica and to get them on your side. Well, they do not find it a good arrangement. Read the trade journals. The doctors say: it doesn’t look like anything; it’s just a moratorium for a year, what do we have about it? In short, you have, if that was the intention, can not buy the sympathy of the doctors at all.

Colleagues, another element of the Health Act is the so-called superpower, the power of the old article 54 and, in my opinion, the new article 58. There is not only a superman or a superwoman coming through that law. There will even be a superpower to oppose you, colleagues.

I hope you understand the scope of this. In fact, from now until the end of this year, the Minister can take all possible measures — which is clear in the fourteen points of the article — to control spending in all possible domains, disregarding the existing consultation structures, but only with effect until the end of 2006, as colleague De Meyer noted. That might make it more dramatic: one asks for such a large instrument, such a supercanon to eventually shoot a few times. At the end of next year it is done and the cannon must be dismantled. The shooting exercises are done.

Colleagues, it’s worse that one buys a large cannon, a superpower, and doesn’t even know where the enemy is. We discussed this in the committee. We have asked the Minister to show us the results and give us the budget figures so that we can properly discuss whether the state of emergency, which is also requested by the State Council, is fulfilled. However, this did not happen, but today. In the financial-economic era of today, there are no more problems in the area of health insurance. On the day — o irony — that this law is being discussed here in the plenary session and that all possibilities to take notice of it in the committee have been turned off, there is such a message in Time. If you want to laugh with the people, it would be better to say it in advance, so that we may be able to laugh with them in the long run.

Colleagues, we are against such powers, because such powers actually mean powerlessness. After all, it has been fifteen years since the department has been managed by socialist ministers, either from the French-speaking or Dutch-speaking side. It is always the socialists who have taken responsibility for this department. You see the budget dissipate and you don’t know what to do. They panicked to look at it. They say, “Give us the authority, that is the solution. We will see: if the account is not correct, we will make them beat. If necessary, we ignore all consultation structures. We are going through. We will say that the rate of that nomenclature or of that treatment is still so much and done with it. Linear measures: the good must pay with the bad, point to line. It should not have been exceeded.”

Imagine: after fifteen years of socialist rule in the Department of Public Health, we have failed to make a fine-tuning. With all the tools that exist today, computer science and data research, we have failed to get a good overview, knowing what it lacks, so that we can take the right action. We have a mountain of laws with corrective measures, blind linear measures, such as claw backs in the pharmaceutical industry. However, they are all measures of powerlessness because we actually do not know how the techniques of health care work, where the money is spent, what it is used for, and whether it is used properly. We have no vision of that. Each time, we have a budget. We add a certain percentage to that which we will not be able to accomplish afterwards. Then we’ll save a little, and then we’ll do it linearly.

Well, my colleagues, that is a bad policy. This is a policy that has no chance of survival. That’s a policy that targets one-shot, a one-year mandate. What happens next, nobody knows. After all, everyone feels that when one has structural problems in the healthcare system, one cannot solve them otherwise than with structural measures that will still work out within five, ten or twenty years, such as with pathology financing, responsibility and the many things that we constantly hammer through the questions and views that we put forward in the committee. But nothing of that: no machines are made, no operational structures. It is said that it will be much easier to do, that it will be easy to do: one calls a full authority in life, and one will then see what one sees.

Mr. Minister, I wish you good luck, because in a sense you have pulled the table layer on your womb. You have drawn the problem to you. The challenge for you and the expectations are phenomenal. You say to Parliament that it should not be awake of this, that it will no longer have to worry about health insurance by the end of the year, because you will arrange it before the end of next year. If that fails — I deeply doubt that it can succeed when I see what you can do and how little structural you can intervene — by the end of next year, then you are, of course, in shame.

You do not let it go so far. You are politically useful and you say you are already investing in the campaign. As a title, let you publish in The Time: "The budget state of the health insurance is under control." The budgetary condition of the health insurance is under control and at that time we ask for a mandate until the end of next year in case there would be discharges. What is it really about here? You told us that there was an emergency state. You also described them. After all, the State Council says that you would not get those powers unless there is an exceptional situation. Today you say that there is no exceptional state, because everything is under control. Why a full authority? What is the purpose of this authority?

I have always loved the art of sophism and paradox but we swim here in full surrealism! I must therefore denounce the attitude I see at the moment.

Even though I, by courtesy, pay a lot of attention to the words of a colleague who loves these subjects and has been following them for several years — I was also a parliamentary on these banks alongside him — we find ourselves here in front of a paradox. First, I am correcting a small mistake: health care has not been in the hands of the socialists without discontinuing. Unless I am mistaken, Ms. Magda Aelvoet and Mr. Jef Tavernier has not yet dismissed his cuti! This is still a difficult department, Mr. Goutry. You have the honesty to acknowledge it: you cannot manage this department like another where budget appropriations are fixed and their execution is controlled as the year goes on. I have previously been Minister of Budget in an entity where it wasn’t easy, I did this job and I can compare.

Here, we are facing a gigantic department, which involves an impressive number of actors. What are we observing? I will comment on this more extensively later but, for politeness, I will still give you some answers. Looking at the figures, we see structural excesses in the department, especially in the important sector of the medicine which we will discuss, in the sector of fees, in sectors related to the ageing of the population.

As you said, a few months ago on the same tribune, you could have a minister who makes balance sheets, who observes, who tries to detect developments and who would limit himself to that. If I want to give the image of someone who engages in a careful observation of things, doing so alone would be merely an intellectual exercise. We need to know how to take action. And there are two types of measures: direct “here and now” measures, which will produce savings, and structural measures. The set of enabling devices you have just mentioned allows you to work, sometimes in the short term and in a direct way, sometimes on structural changes.

With regard to the current financial and budgetary situation, things should not be confused. What I reacted to was incorrect information published in the newspaper "De Tijd", according to which, beyond the measures of economy that I encourage and that I seek to implement, in particular through the arrangement that we are discussing today, there would have been a surpassing of the order of half a billion euros for 2005. This is what I reacted to. It’s inaccurate and I once again wanted to cut off the wings to a duck that seemed to me flying a little too fast!

Are there no more difficulties? This is the question you are asking. Certainly, a number of difficulties persist in all areas: the control of costs and how to respond to them. This is also the subject of the legal arrangement which we will still discuss extensively today.

Mr. Minister, in the discussion of the Health Law in the Social Affairs Committee, I paid attention to this point.

Mr. Goutry pointed to an article in The Time. However, this was not the first article. This week has already been done on this issue. Mr. Minister, without wanting to go into exaggerations, I must read from the heart that I was a little scandalized that there would be no problems in health care. If the exceeding is less heavy than some feared, you find in me someone who rejoices immensely about it. However, let us not forget that there is still a heavy excess on the growth rate of 4.5 percent. That there is no exceeding of the exceeding, I am pleased. But that is the only thing. However, the excess remains.

In the committee, I explained my disappointment about this health law. A disappointment that increased after its amendment in the committee. Where do I insult? I regret that at the time when the growth rate was introduced – ⁇ not realistically – of 2.5%, then from 1.5%, later increased to 4,5%, we did not provide for controllable and enforceable instruments to stay within this 4.5% growth rate. Since then, we have been able to assume that we have never stayed within that 4.5% growth rate. That is my great accusation.

In the Social Affairs Committee I have stated, even as an opposition member, that I am very willing to approve special powers or powers. I was not dirty of it in 1995 and I am not dirty of it in 2005, but on the condition that these special powers are used properly. Mr. Goutry has already pointed out that kiwi has become a kind of fig. The only resemblance is the rough skin. For the rest, there is nothing left of any comparison.

Mr. Minister, from the figures of the excess of the budget — not the excess of the excess — it appears that it must again be sought primarily in the medicines and not in the fees. I have trouble with that. With the current provisions in the Health Act, you have, in my opinion, made a few concessions too much to the lobbying of the pharmaceutical industry to hold the instruments in hand.

Let’s bear in mind: the fact that one must pay a part of the excess I find — I rarely use the term — ethically perverse. First exceed and then pay a portion of the excess is not the right system, there should simply be no excess. I could go further on this, but that is not the purpose of my intervention.

Mr. Minister, I would have liked to give you the powers, which I have also said in the committee. However, I am afraid that you have removed the powers. I think it’s a missed opportunity: I’d rather have given you 20% to 25% more powers than the 50% to 60% that have become.

As I have already said in the Committee on Social Affairs: as the government has put “purple on white” on paper, by 2007 you must not remain within the 4.5%, but must further reduce. The growth rate should not be 2.5% more in 2007 because that is unacceptable. This was clearly stated by the government. However, we are not yet able – as it will be in 2005 – to stay within the 4,5% and yet we must return to 2.5%!

It was not written by me, but is found in the texts of the government agreement. How will you accomplish this in two years? This health law should have helped you in this, but is too weak for it. Within two years we will not have reached the 4,5% yet, let alone a reduction in it. If I have something to blame you, it is.

I would like to get in here for a moment. When I read The Time this morning, my bump broke. Today, the Minister comes to Parliament asking for a blanco cheque, for extensive powers. His argument to the Commissioners concerned is that he needs the powers as a stick behind the door in case it would run out of hand. Through his cabinet chief, the minister says today that there will be no problems for the current year 2005. What are these powers for, let me explain? Why should we vote on this health law today?

Furthermore, I think you should urgently consult within your majority, Mr. Minister. I will repeat it as soon as possible, hoping that then some colleagues from the MR group will be present.

Earlier this weekend, the MR group, the House group nota bene, under the leadership of its group chairman Bacquelaine, who knows a little about the dossier, made a very sharp statement. They were sentenced to place you within government under curatele. Mr. Minister Demotte, in other words, they had no confidence in you anymore and wanted the figures to be submitted every three months, in full Council of Ministers, to all members of this government.

Mr. Minister, it is one or the other. In the article in The Time you say in good old socialist tradition that there is no problem, "let the money be thrown further through doors and windows", while everyone who knows the file knows that the home of the health insurance is on fire.

Mr. Minister, you are beginning to show painful similarities with those famous generals in Iraq. At a time when the Americans stood in Baghdad and Baghdad was indeed in fire and flame, they still pretended there was no dirt in the air. I am afraid that you will be strongly compared to such Iraqi generals who, at the time that the whole tent was on fire, did not yet see that it was on fire.

Mr. Speaker, I can’t get rid of the impression that ⁇ contradictory messages are being brought out here.

I hear Mr. Goutry on the floor saying that there is today in The Time that there is no problem. He asks why authorities are needed. He says his party is against those famous powers.

I hear another voice from the same group. He says that there is still a problem, because there is indeed still an exceeding of the 4.5%, that the faction is therefore not so dirty of powers on condition that they are to the point and that one really has an instrument on it for a limited time. This is what CD&V says.

It adds that these powers have been exhausted and that they have been redeemed by the pharmaceutical industry. That is the core of the speech. After all, the patented medicines have been taken out and the pharmaceutical industry has bought out.

I would like to point out here, however, that during the discussions of the Health Act, the CD&V group at the forefront of the respected colleague Goutry submitted an amendment to remove the patented medicines.

The argument for this was that one should pay attention, among other things, to the research in our country. This is an amendment of the CD&V group. To be honest, I no longer understand it. Who is speaking on behalf of what?

Mrs. De Meyer, if you have difficulty, then you must answer with arguments the things I have said. I have not talked about patented and non-patented medicines. I talked about the spending on medicines.

If you find that the spending on the medicines in this country, with this health law, is correct, say it. I will repeat it everywhere. I didn’t talk about subgroups. I have said that the spending on the medicines in this country is not correct. You let them out.

I listened to the various speakers. It seems to me that the common concern is, today, the control of spending. So it’s not enough to have a reading of the current numbers or, in a mirror logic, to read the figures of yesterday. There is also a prospective perspective. We are faced with problems of time control. I am not the captain who drops the bar of the ship as soon as a large wave appears. I will never compare myself, like Mr. Bultinck had the audacity, to a general; I have not the warrior mood. But, in the difficult circumstances that are those of health care, one must maintain a direction. What is it?

It consists of certain measures of structural and non-linear economies. We will return to the question of care basins which seem to me rather to be areas of "chalandise" of care, not to program the infrastructure, but to offer answers to the needs of care. I think of primary needs in terms of oncology, cardiological treatment, etc., which do not all correspond to identical regions. We can speak here of regions that are defined not only by geographical criteria or distances, but also by populations, socio-economic profiles, comparisons in the field of "evidence based medicine". There are many criteria involved. This law allows for progress in this direction. It also responds in part to the requests made by our colleague Greta D'Hondt.

For medicine, we are facing a serious problem. Because, if you look at the figures, you can see that they show that the majority of the effort goes to the sectors that exceed the limit and, in particular, that of the drug that is around 380 million excesses. As the exhibitions and my intervention progress, you will see that extremely serious measures are being proposed for the drug policy. We may have a debate about the contradiction between those who wanted to keep drugs under patent in the framework of public procurement and others. But the main thing is that this device does not close any doors, including – in some cases – compared to patented drugs when it comes to “me too”. And I will reply soon to our colleague Drèze who will question me on this subject.

We give regulatory tools and some facilities to CRM to identify “Copycat” or “me too” drugs that don’t add value, not only to the company – Mrs D’hondt, you know well – but also to individuals. Because we pay double as consumer patients and, overall, as a society.

Now, I say that the measures we propose today through these texts amended by the Commission remain perfectly relevant and that it is always urgent to take on certain expenses that need to be controlled.

Mr. Goutry, can I ask you to go on and finish if possible?

Per ⁇ even a response to colleague De Meyer because the debate is interesting, it needs to be carried out, it is necessary. Only, Mrs. De Meyer, it makes no sense to make it a political jenery now in the sense that you say this and you say that. It has nothing to do with it. Will you agree that we have been saying for years that there is a big problem in health insurance? We have said that for years. Of course we have said that for years. We have been saying for years that they do not get there, that they exceed the growth standards, that they do not have mechanisms, and so on.

Frank Vandenbroucke, honourable, is the one who has indeed created a number of corrective mechanisms that allow us to keep the matter still a bit straight today. If we can keep it still a little, then it is because we have an instrument — one calls it in good Dutch claw back — with the medicines such that the excess is recovered there for 72% later. That is the only thing we have left that Mr. Vandenbroucke has made. Then he made legislation in which he was preparing the case, in which he wanted to go to responsibility, to the core of the case. He wanted to address the matter structurally, Mrs. De Meyer. He wanted to place everyone for his own responsibility.

So our criticism is not that there are no shortages and that there is no need to work on them. of course . However, we are talking about technology. The technique of a full power involves that if someone no longer knows how to defend himself, they are given a super-large cannon. Then hide and let him shoot with it for a certain time. Then they say that it is done and that he must return the cannon. He had to shoot, he had the time.

and no. It is about continuous intervention within all possible consultation structures, within the mechanisms that force spending in health insurance. There one must have the finger on the wrist, there one must immediately see when the water boils, there one must apply good corrective mechanisms. Then one will never get to such a state. That is the right thing. It is about a technique. Power is powerlessness. In other words, it is no longer seen. It has to be done and if one goes over again, we will put our foot in it. We will cut off with the knife. What are we going to cut? You know in advance that you are going to do things with which you are chasing people against you, precisely the people you need to responsabilize, people who should actually be behind you. This is the issue, and nothing else, my colleagues.

Mr. Minister, I would like to say one point about your newspaper report. You did not give it yourself, it was Mr. Witmeur, your cabinet chief, who gave it. I hope that he is less aware of it than you are, because what stands here, on page 3, is actually clear nonsense. You would never have said that, you know the matter. Probably not your cabinet chief. I am surprised, but I have to admit that there are terrible things in this. This means that there is no problem because of the austerity measures you announced in September and November. What were they? I searched for them again. These were the reference compensation and the group-based revision of medicines. Mr. Witmeur says we are going to overthrow. He says these measures have already been implemented. That is doing well. Colleagues, they have not yet voted, how could they have already applied? They have not yet been voted. What have you done yet? It’s right, you’ve done one thing that’s rewarding: you’ve kept the indexing of the doctors immediately for you. That is the group where there are the least problems, but that has been chasing you in the curtains for months. However, you did that. You said that in the envelope for biology there should be an update. I checked that: there is no measure so far. There was already something announced in November about rational prescription behavior. In your measures in November it was announced that we should be able to prescribe on the name of the dust. I have not read anything about it in the Belgian Staatsblad; there has not yet been published a jota about it.

Ladies and gentlemen, what are we doing right now? Either we cheat each other, or we give interviews because we think that half of Flanders do not know and understand this and only look at the title. Do you notice that one looks at the title and the people in Flanders start to wonder what one is tired of dealing with the Health Act and the health insurance, as the newspaper says that everything is under control? Is that the intention to get together in debate on the day we are discussing this?

By the way, Mr. Minister, I am very pleased that your cabinet chief explains something based on the figures of January and February of this year. Two weeks ago we asked in the committee for your figures and for the state of affairs. Then the minister said that he had no numbers yet and that it would last until May. I read you the logic of such articles. “We will not spend any more euros,” Minister Demotte said. Then Mr. Witmeur says: "A updated state of the savings shows that they produce slightly more than originally planned." We do not yet have half of them in implementation and they are already raising more! This is wishful thinking. That is thinking that something brings and it will follow. Mr. Witmeur says he has the figures for January and February, but says a little further that more figures will be known at the end of May. What are we actually doing now? We already have numbers from January and February and we have those that should never be used. It is right, because it is said that one should not use the numbers of a month to extrapolate. One does not even dare to extrapolate six-month figures, because one should pay attention to debuggeting techniques: one may send invoices bundled in January and that are misrepresentations. Now they use the same numbers. When we asked for numbers in the committee, they were not available.

Mr. Minister, I am very upset that on the day that we are here no longer have a chance to say it, unless a moment on the tribune and we can no longer ask for a hearing to clarify the figures, your cabinet chief says that he knows up to the minute and the second how it is for January and February and that the rest follows in May, but that we will exaggerate more in terms of savings than thought. I am stunned.

To my knowledge and so that there is no confusion about the numbers, it is not accounting figures that have been commented, it is raw material. Indeed, if this information is in the press, it can only be T20 documents, that is, cash documents for the first two months.

I am someone very cautious. Treasury documents are not accounted documents. In other words, I will actually wait to see in May what amounts are actually accounted for in the first months. The treasury would rather give an indicator of favorable evolution. Even taking into account what Madame D'Hondt taught us last year about the evolution of social security spending, the first months are extremely indicative; but it is always just cash. Let’s take information for what it is. If it could be encouraging, I would be very happy with it, but I repeat, this is just cash documents.

I remain from one surprise into the other.

I would like to read one last quote. After that, I will no longer talk about this. Maybe I can do it better elsewhere. Mr. Witmeur states, I quote from an authoritative newspaper on this subject: "The government in November assumed savings in 2005 in the amount of 504 million euros."

Mr. Minister, I would like to remember that we discussed this issue at a number of committee meetings in November. There was always talking about 350 million euros, never about 504. We have taken into account the claw back of the pharmaceutical industry, which would result in the savings and the claw back of 500 million euros.

What are we dealing with if the corrective mechanisms that must be repaid in case of excess are also counted as savings! This would mean that someone who goes over the amount and claims it back can claim to have made a savings. This is not a savings at all. Initially it remains the same. The only difference is that the excess that was spent was received again. In short, Mr. Minister, this does not cut wood. Most of all, I am worried that Mr. Witmeur says that the savings will bring 516 million euros.

Mr. Speaker, Mr. Minister, the statement you made recently is very important.

With this statement you say about the following. “My colleagues are careful. These are preliminary treasury figures.” Indeed Mr Minister. These are very preliminary figures. With this, you nuance, moreover, you send the statement of your own cabinet chief again.

I hope you understand very well what you have stated at this particular moment in this Parliament. I’m afraid you’ll get right and your cabinet chief—per ⁇ someone from the old PS stamp—is a little too euphoric, and it’s just to pretend that the numbers fall. I am afraid that it will not happen and the preliminary thesaurus figures will indeed be very preliminary. Mr. Minister, there is no logic in this. Why would it suddenly go so much better in the first months of 2005 after the dramatic year 2004?!

Mr. Bultinck, T20 documents actually provide information about the Treasury. As cash and accounting do not always do very good household, there may be differences. These figures should be interpreted cautiously.

For some time, there was an information circulating which I had also referred to myself in responding to Mr. Goutry, and which concerned an additional surpass of ⁇ half a billion for 2005. The journalist relies on the T20 documents which are the only information we have at the moment; we cannot confirm these figures.

Mr. Speaker, I will conclude with a few words on medicines. We have debated this in the committee for a long time. Everything that would be done with the medicines, by the way, was read in the newspapers long before the Health Act. Only all the previous statements of the gentlemen Stevaert, Demotte and others must ⁇ not be placed next to the final result with regard to the medicines as stated here in the law. It does not seem to be.

Mrs. De Meyer now throws the ball back to me and says that I also had submitted an amendment that the drugs out of patent?. of course . I liked it better, but you said you ⁇ ’t do it. Mr. Stevaert had said that he did not attract himself at all whether it was under, outside or within a patent. They all had to be put in the pot and compared with each other. This is what Mr Stevaert said.

We already said at that time that the Kiwi model would not succeed with us, that innovation would be cut down and the people who wanted to develop something else would reverse that. He replied that this would not be the case. One would change all that, all in one pot, all they would have to give up and with it out. Then, however, these same socialists submit an amendment from the majority saying that they have thought out and yet will make a distinction between the medicines with or without a patent.

We submitted that amendment because we wanted to correct the big mistake made in the law. Now you do it yourself and say afterwards that we wanted to do that too. In other words, you have said everything about it yourself, and in the end, very little comes out of it.

I want to say the following. The Bond Moyson booklet will be the introduction of the new drug policy. That booklet was distributed note bene the morning that the Health Act should be approved here. We have been asking ourselves for a few weeks why we didn’t continue with the health law. Now we know. This book was being printed. I can imagine that there has been a lot of pressure on it. It is a beautifully colored booklet of 160 pages.

What has happened? At a certain point, Mr. Mayeur was called from the printing office to ask him to stand a little bit on the brake in the committee because the booklet was not yet finished. I call you as a witness. Certain committee meetings were closed at 14.00 or 15.00 hours. They said it wasn’t urgent and that next week would be good too. In the last days, the last week, it suddenly couldn’t go fast enough and they wanted to pass that bad law on Thursday. Why Why ? The books were distributed Thursday morning. That was the apotheosis of the whole plan-Stevaert. He had all his plan well prepared on the cap of Minister Demotte. As a blow to the firepile, the Health Act was discussed today in Parliament. People, here is the booklet, read it and you will see what we have done.

What’s in the book, by the way, has nothing to do with health law. It is about reference prices. What is said in that book? It’s very interesting, I ⁇ won’t throw it away. However, you could have printed it years ago. It has nothing to do with the health law.

and .... Clearly a correction because two weeks ago you found the book very bad. I made such a booklet myself a few years ago and it is not obvious to plan it so that it appears on the same day as the approval of the Health Act. Chapeau for the creators!

No, Mrs. Detiège, the work in the committee was allowed to take exactly that long because the booklet was not there yet. I explain this exactly. You did not listen.

What is there, colleagues? Very very interesting. It is very beautiful smooth paper. That costs a lot of money. But it is also the trouble. I will not smash it away. I’m going to stick a stick over the Bond Moyson emblem but for the rest I’m going to use it.

In diseases of the nervous system, for example, Nestrolan is shown in blue. This means that in addition to Nestrolan, there are also Doctrazodone and Trazolan, all with the same molecule. One compares the prices and one puts Nestrolan at the top of the blue bar to demonstrate that this is the cheapest drug. This is very interesting, but we already had this with generics and the reference refund. What does this have to do with the health law?

The drama is exactly that from now on every citizen will have to have such a booklet with him. That is the danger of this law. Everything is in the camp of the prescriber. The patient is completely out of play. If he does not have his booklet with him, then the doctor prescribes something for him, he goes to get the remedy and then notes in his booklet that he was prescribed the most expensive. From now on, colleagues, every patient should always have that booklet with them. You will need to have it with you because otherwise you will not know if you were prescribed the right medication. Here, this book.

I am really surprised. I really fall from one surprise to another. This is a booklet from the National Union of Socialist Mutualities. The CM or the Christian Mutualities have been doing the same thing for years. I feel that a certain frustration comes up here because I really find no other explanation for these statements about that book. Both mutualities have had such a booklet for years.

If it has existed for years, why are you standing in the morning of the treatment of the Health Act with it then at the stations?

Information to the public is important.

Tell it in the pharmacies or give it to the doctors, but do not distribute it to the stations. I give something to the stations during the election campaign. That is to say, you do this to flourish yourself and show how fierce you are. In the problem of medicines, this is exactly the problem. In this respect, there is an essential difference with kiwi. Kiwi makes a booklet that contains only ten pages and contains the best medicines for the best price. This is the system that Mr Stevaert foresaw us.

And what did he do? His book has become even thicker. It is very interesting but it makes the patient very vulnerable because if you don’t have that leaflet, you are guaranteed not to know if you have the best medicine. You should not tell a pharmacist if he agrees to give you the "eighth product" because it is much cheaper. The pharmacist will say, "Brave boy, go back to the doctor for a new prescription because I can't deliver that because I can't substitute."

First, a first reaction on the somewhat dilatory nature of the commission work that would have allowed mutualities and printing companies to find time to disseminate their booklet: I therefore thank Mr. Goutry granted permission to grant this deadline. Personally, however, I was not informed of this publication and I discovered it at the same time as him.

More seriously, a second element concerns the issue of medicine. The fundamental question at the heart of the economic measures we must advocate is this: Are we achieving our financial objective while respecting free access to medicines and therapeutic freedom? It is in this spirit that we have tried to tailor measures that, on the one hand, respect our original idea — to ensure that doctors, who have a prescription role to play, issue prescriptions for cheaper medicines — and, on the other hand, allow us to establish structural mechanisms.

The process we are implementing in Belgium is of a structural order and – if the word did not have certain connotations – “revolutionary” in relation to our ordinary practice. Indeed, we will put drugs in competition, even if we limit the field to drugs today without patents, and this with a double goal: a goal of collective economy and the maintenance of the freedom of everyone to access the best possible molecule. There is no controversy on this point.

Mr. Minister, dear colleagues – and in particular to the socialist colleagues – I would like to add something. I am troubled if the fulfillment of "therapeutic freedom" would involve that someone who is trained to know that a medicine has the same therapeutic value, in the context of the so-called therapeutic freedom, still prescribes a more expensive agent and makes the price pay by the patient. That is a therapeutic freedom that I cannot live with, let that be clear.

To the attention of the green-tinted socialist colleagues: trees could have been saved if one had not worked with a booklet with all sorts of — whether blue or other colored — bars. I am not talking about the booklet in itself, but about the moment of the health law that should have been addressed. This is also the case with the reference reimbursement, and I have trouble with it. We have very competent doctors and very well-trained pharmacists in this country; we must therefore be able to say which medicine for which condition has the best price-quality ratio. It is possible that there are two medicines, but nevertheless not a whole series of — as in the booklet — colours and bars. The doctor can then choose between 1 or 2 medicines, which can be provided by the pharmacist.

Now it is the patient who ultimately pays the leather, even after the Health Act. Maybe I can live with it — tomorrow and tomorrow I will undoubtedly be here again — but I don’t want to accept it. I speak to both my own group and to the majority — with the socialist colleagues — when I say: you missed the opportunity. Whether it’s figs, kiwi, or apple seeds, it doesn’t matter. If the law is passed tonight, it will be the patient who will pay the layer.

Mr D’Hondt is absolutely right. The patient is placed in a vulnerable position. The policy is proposed as a policy of cheaper medicines, but all the consequences are transferred to the patient. The responsibility lies with the author. Doctors, however, say it themselves: there are so many medicines; for example, there are 70 anti-inflammatory agents, how can anyone get rid of them? Of course, they can’t get involved with scratching out all the books.

That is the conclusion, Mrs. De Block. If the older drugs are made cheaper, you also know that a whole trits of new drugs are immediately prescribed. Not the pharmacists or the patients, but the doctors prescribe them.

Colleagues, I wanted to point out that it was a hypocritical matter. Fortunately, there are also medicines against this. It has been a hypocritical affair, in which a whole campaign has been launched — for months — and the Flemish people have wanted to announce that there would finally be a serious drug policy of which everyone would get better. There are indeed improvements. There are many things in which we support, but we must dare to say that it has been reversed, modified, changed and processed in such a way that it is even more complicated than before. That is the conclusion.

We will stop the session this morning around 13 o'clock, after the intervention of Mrs De Block.

Mr. Speaker, Mr. Minister, colleagues, considering the advanced hour, I will not make my presentation too long and limit myself to one topic. My colleague Avontroodt will talk about the rest this afternoon or tonight.

I think it is important to highlight one issue: the re-alignment of the nomenclature. Nomenclature is a word that has already been used in many cases. Since not everyone is always present in the committee, I would like to explain that this is a key tool for the functioning of our health insurance. The health insurance includes, as you know, a scheme for the compulsory insurance of medical costs in case of disability and illness. The nomenclature is a limitative list of the medical services for which the health insurance includes the costs. Each performance is accurately described, coded and financially valued. You have already said, Mr. Goutry, this is indeed a very important instrument.

The RIZIV is responsible for the management, control and financial policy of this insurance. As you said, this is, of course, always in the patient’s interest. Article 35 of the ZIV Act provides that the name list of medical services or the nomenclature shall be drawn up by the King. This procedure is long and heavy. The Technical Councils of the Medical Care Service make proposals to modify these lists over time, taking into account the evolution of science. The Insurance Committee of the Medical Care Service shall then decide which adjustments to the nomenclature shall be sent to the King, with the proposal to adjust this list. This is a long-term work and even a true titanium work. In view of all the other tasks these committees have, it is not always obvious to allocate the necessary time for them. Therefore, there has been a delay in the adjustment and re-alignment of the nomenclature.

Colleagues, you know that the re-alignment of the nomenclature in 1999 was included in the government declaration of the purple government. At that time, it was already known that there was a backwardness and that there had to be a collection movement. The then Minister Frank Vandenbroucke has done his best for this, but has never succeeded in getting some dynamic in it. He has done a lot of good things, but he has also sometimes walked his nose against a wall. I have repeatedly asked and pointed out this in the committees. I asked questions and interpelled about when and how the nomenclature would be revised.

When it turned out that it would not be a loose roof, I together with colleague Vandeurzen submitted a bill to set up a committee within the RIZIV and charge it only with the inspection and re-alignment of the nomenclature. That bill is still in the form of an amendment incorporated in this Health Act. I am very pleased that it was adopted by the Minister.

Colleagues, it is not our intention to add another committee to those 150 RIZIV committees. However, the committee will have one clear task: with the necessary expertise to bring about a re-alignment of the nomenclature. I will briefly repeat the strengths of this proposal. The Committee will be tasked with formulating opinions on the following matters: first, the simplification of the nomenclature of medical benefits by adjusting or grouping benefits, including in the context of well-defined disease images and care programmes; second, the revision of the ratio of the relative values of the benefits, taking into account their cost cost, with the available scientific evidence and with other factors determining the objective value; third, the introduction of new rules on the conditions for the accounting of medical benefits with a view to a more efficient utilization of the resources; fourth, the introduction of new benefits on the basis of an assessment of the technology concerned and the reduction on health insurance providers. As you can see, the committee is given a very well-defined task, which will require results to be obtained faster. In addition, we provided a health economist for the committee.

The establishment of the Committee is an important step in the more than necessary control of the budget of our health departments and also of the adjustment of the nomenclature. As I said, the task is huge. The underlying balances are fragile and the task is thus delicate. Eliminating unnecessary numbers and limiting indications are not popular orders, but at the same time they are absolutely necessary to create financial space for new numbers, new refunds and new performance. The re-alignment of the nomenclature is a task that will never end. The evolution of science means that adjustment must happen permanently. The Scientific Council shall ensure that the adjustments are thoughtful and scientifically accountable.

That the approval of our proposal does not come too early can be illustrated by a recent article in the Journal of Health Law. Mr. Goutry, this is important to you, because you say that the patient should not become the child of the account. That article, in fact, deals with a judgment of the Council of State of 2 October 2003 concerning a legal conflict relating to a gynecological procedure for which there was no up-to-date nomenclature number.

The doctors had to make an interpretation of the nomenclature in order to be able to bill a laparoscopic procedure. This is also a known problem in the accounting of hospitals. It is a beautiful example of the sometimes too large distance between the medical reality and the current nomenclature.

The State Council destroyed the sanction that the doctor had imposed for the interpretation of a number, and justified the doctor. With their arguments, they hit the nail on the head. The State Council correctly stated that all regulatory bodies should establish clear regulations. Since the nomenclature is normative, it should be formulated as clearly as possible. They add that pluralistic, vague and indefinite terms are contrary to the principles of good governance. In the present case, the nomenclature was not adapted to the latest developments in medical science and should therefore be qualified as insufficiently differentiated. That too vague formulation of the nomenclature, says the Council of State, should not be read at the detriment of the doctor.

At the same time, the judgment of the State Council severely diminished the unlawful interpretation practices. The State Council rightly pointed out the inadmissibility of a pseudo-nomenclature. Because changing a nomenclature goes harder than the evolution of medical science, one began to interpret the nomenclature. In this way, benefits that were not included in the nomenclature were compensated. This leads to an untransparent accounting in the RIZIV, but also in the hospitals. Then we hear the patient say that they do not know what is on their invoice and that they cannot infer from what treatments have occurred. The patient is also the victim. In this way, benefits that were not included in the nomenclature are compensated. In order to guarantee legal certainty, the Program Act decided to publish the interpretation rules in the Belgian Staatsblad. This was done at the initiative of Minister Vandenbroucke. However, this procedure has also proved to be little dynamic.

The judgment of the State Council confronts us, the legislators and the competent minister, with the legal facts. The responsibility to come up with a clear nomenclature, but also a nomenclature adapted to the scientific state of affairs, also lies with us. The proposal for the re-alignment of the nomenclature, but more importantly, the ongoing effort to adapt the nomenclature to the medical reality, is therefore not too early. The too easy transfer of financial responsibility to the doctor or to the patient, Mrs D'Hondt, has been stopped by this judgment.

I look forward to the achievements of this committee in the future. I would like to thank my colleagues for their interest.

April 13, 2005 | Plenary session (Chamber of representatives)

Full source

Mr. Speaker, Mr. Minister, I would like to return briefly to the prehistory of the important bill we are discussing here today. Their

You will undoubtedly remember very vividly the beginning of your own mandate. You started organizing health dialogues in a very well-laughing style. We still wonder what ultimately the concrete results of those health dialogues are, but that will undoubtedly be of less importance in the story of perception.

Already in the autumn of last year, a number of questions were asked regarding the financial situation of healthcare. Ultimately, it was not until November 2004, after the publication of the first truly alarming reports on health care shortages, that you, as a minister, spoke very clear language for the first time, and through the famous note, communication to the actors of health care, came with concrete proposals for the day.

Mr. Minister, in the last few weeks, without correct figures and without being 100% sure of the numerical material that we should actually be able to possess following the discussion of such an important bill, we have been able to calmly take the time to discuss the current bill in the committees for Public Health and Social Affairs. In the meantime, we already have the numbers, since the beginning of April. The final deficit in health insurance for the previous year 2004 amounted to more than 513 million euros. Their

Mr. Minister, I would therefore expect each of us, beyond the boundaries of majority and opposition, to realize the seriousness of the situation at this moment. Their

Mr. Minister, I must honestly tell you that my bump broke this morning when reading the article in The Time where mortality stood: "Budget state health insurance is under control. Minister Demotte will not even have to look for additional billions due to the budget control."

Honestly, I can no longer understand it. Also in my second attempt I must find that the banks of our liberal colleagues, ⁇ the colleagues of the MR who swing a little between the future opposition role that is undoubtedly close to them, are thinly populated. Sometimes I can no longer understand them well. What did they say over the weekend? They would indeed place Minister Demotte under curatele because they no longer had confidence in this PS-minister; they wanted that in the future the figures would be presented integrally to the entire government team. This can count, Mr. Minister. In the course of the afternoon, when the members of the MR want to be so good to come back again for this important debate, I will make an attempt to address them themselves and listen to their statement.

I come to my second important element. Where is the time when the generic drug sector was very satisfied with the policy? Today I take note that prominent figures in the generic drug industry dare to say that this health law — who thinks it possible — will incur additional costs. This is a first very concrete and relevant question, Mr. Minister, to which I would like to receive an answer. To get closer, I assume that this health law was meant to save. Each of you has always said that this is a budget document. I now note that a major sub-sector, that of the generic drug industry, warns that this health law will cause additional costs. Their

Mr. Minister, however, there is a fundamental difference in approach and offering possible solutions between members of the opposition and members of the majority, with regard to the health law that is now being discussed.

You have humbly acknowledged choosing a budgetary document requiring extensive powers from Parliament. Then the problem is solved.

The Vlaams Belang group would have much preferred that the precarious situation of the health insurance would be used to conduct the fundamental debate. In this regard — a first clear statement — this bill is for us one of the missed opportunities.

Colleagues, I would like to make a cautious effort to open the debate and send out the fundamental direction. Let us first look at the entire financing of social security. The disastrous financial situation of the health insurance and, if expanded, of the social security, would require us all, beyond the boundaries of majority and opposition, to conduct the fundamental debate on the financing of the social security. The Flemish Belang Group will continue to insist on this. Therefore, I am making a new attempt today to conduct this debate in a serious way.

It will take much more than a polite request from the government to the social partners to consider additional or alternative financing of social security within six months. Everyone knows the current system of social security, which is mainly financed by social contributions from employers and workers. Even though a number of interventions have taken place in recent years in the direction of alternative financing through VAT income, the entire system has remained very labor-destroying. Recently, the Prime Minister again used the old Vivant balloon net to raise the consumption tax. Fortunately, the idea was just as quickly rejected — including from the construction sector — as deadly for the internal consumer market.

Mr. Minister, despite all the drumming that these days is still being given by the liberal factions, in our country in practice no reduction of the fiscal and parafiscal pressure has been carried out. Therefore, we and our group must and continue to consider it useful to continue to make a fundamental plea for a different financing of important parts of social security. Let us just call it by name: it must be financed from the general resources. We should not continue to push in the margin, as we are now doing.

Mr. Minister, a second important item that I would like to cut, after the item of the financing of social security, is the entire understanding of the organization of social security.

In this regard, we may have had the same perception. You will of course not be able to admit that as a competent minister, but the story of the Health Act, Mr. Minister, has been primarily a story of media perception.

The last few months have been characterized by an enormous profiling urge by SP-A party chairman Robert Stevaert in the health insurance file. With its famous five-camp, Stevaert organized a real media circus with proposals that were not even new. They were already put in the hills by the former Minister of Social Affairs, Frank Vandenbroucke. Can politics as a special form of cynicism be even clearer?

To my great surprise, you were not upset. You did not react irritated at the profiling urge of Stevaert. On the contrary, as a PS minister who really realizes that he is facing a perception problem in Flanders, you were actually satisfied that Stevaert went with all media attention. It is not a coincidence that in the last few months, the adage about Stevaert reads as follows: “He is our best spokesman in Flanders. He does not take over the discourse of the division of health insurance, but recalls the strength lines set out by the federal government. It’s fun.” end quotation.

Not by chance, Mr. Minister, you realize, better than anyone, that you will have to make yourself strong in the face of Flanders to give the impression that after the approval of the Health Act you will be able to carry out so-called Flemish sanctions. I’ve told you before: you’re a very good tactic at times. By analogy with the PS’s stance on the federal wage agreement — an agreement that the PS also swallowed a little against its will but that it eventually swallowed for tactical reasons, in order to prevent the debate about regional CAOs from being held — you must now as the PS minister create the impression that with the approval of the Health Act all abuses in the health insurance will be eliminated.

I will have to disappoint you, Mr. Minister, even if you have not expected anything else from me: for us, the famous proposals as they were formulated by the Flemish General Hospital Consultation at the State-General of 22 November 2004, remain indeed standing.

Colleagues, I am fully aware that in a debate about the organization and therefore also about the communitarianization of social security, it is in this House actually "not done" to conduct this debate. But as a traditional torture devil, I will do that again from our group. I will outline the main points and the main arguments in this regard. Allow me, my colleagues, to add them briefly.

When it comes to the organization of social security and we are advocating for our own Flemish social security, Mr. Minister, it is from the concern that we can actually lay our own policy clamtons. In the end, what is more personal-related matter than largely health insurance, health care and, in extension, the entire sector of social security? In this sense, we also find in the famous Special Laws of 8 August 1980 sufficient rational and legal arguments to actually start working on the development of our own social security system. It is no more than logical that it would be treated as a personal matter.

A second very important element in the debate, Mr. Minister, is: the efficiency of the policy. This is one of the new fashion words. You should be aware that the current fragmentation of powers between the central state and the counties, where very important matters are held centrally and a number of others are transferred, does not lead to an efficient policy, but rather to a paralysis of that policy.

It is not a coincidence that very prominent top officials from the Flemish administration have been pleading for a very long time to transfer health care to the Communities. You will say, "Mr. Bultinck, I am used to that tone, it is the classic Flemish egoism, the classic reflex that one would no longer dare or want to be solidary with Wallonia." I would like to discuss this again, Mr. Minister. We see that debate rather as a debate of efficiency, as a debate of putting our own emphasis. It has nothing to do with Flemish selfishness, far from that.

Mr. Minister, a third important element in this regard is of course the concept of "responsabilisation", another fashion word that is so in our health insurance. You should know that, if we want to pursue an efficient and economical social security policy, it is not enough to transfer the power over the various sectors from the central state to the provinces. It is well known that the assignment of financial responsibility for the spending of a given budget promotes a certain consideration of spending. Let us keep it simple: Let us compare it, on the one hand with a child who receives a limited amount of pocket money per week or per month and must manage that amount, and on the other hand with a child who receives pocket money whenever he asks for it. You know very well that accountability would increase when a state is held accountable, including for the collection of income. Compare only to that first child of the latter, that same child who has now grown up, is responsible for his own nutritional gain and thus even better realizes the values of the earned money. Therefore, the allocation of financial and fiscal responsibility is indeed the best guarantee for conducting an efficient and consequently cost-effective social policy, it is the best guarantee to prevent misuse in spending.

Colleagues, in this fundamental debate I would like to again call on everyone to have the courage to take this debate really fundamental about the organization of social security, because, as colleague Goutry has already said this morning, we continue with the discussion of that bill actually — forgive me the crude expression — prutsen in the margin. We are not moving toward an integrated policy, we are not moving toward a global vision of the whole problem.

If, then, from the large, ideological, general and fundamental debate on some concrete aspects of that health law I can enter a little better and deeper, then I have no problem with — let me start with the positive news — to boldly recognize that we can also with our group fully support the reform of the special solidarity fund. If it is good, then it must also be possible that we from the opposition acknowledge that it is good.

Mr. Minister, a second important element of your Health Act is the entire arrangement in which you provide the accreditations with the possibility to sanction if the doctors do not follow the rules of good prescription behavior. You have understood, meanwhile, that the doctors have a fairly bitter little enthusiasm for that concept and for that practice. Of course, nobody can have a problem with the concept of "rational prescription behavior", but it would be useful if we get very correct typologies and definitions. How is it described and described? The fact that the doctors are punished for additional administrative obligations in this regard is more than understandable. By the way, we must, in the whole debate, abstain from the perception where, in general, too much of the responsibility is placed exclusively on the doctors. Let us also have the courage to say, as politicians, that there is indeed also an important part responsibility with the patient who must be responded, in which the patient must develop a change of mentality: he must get rid of the idea fix that, when he goes to the general doctor, he must also come out with a prescription for medication. As politicians, we need to have the courage to explain this.

The following important element is in my preparation under the title: "Symbol struggle with the pharmaceutical industry". You will undoubtedly remember my very long speech in the Public Health Committee. I then warned of the extensive form of war rhetoric that came from the original designs and texts. On behalf of my group, I pointed out the importance of scientific research and employment. Now we see that a big curve was taken: the kiwi was cut through.

We were very critical of the Kiwi model, the system of public procurement. You now say that some technical improvements have been made, the system would now only apply to non-patented medicines. Eventually, a major deal was concluded with the pharmaceutical industry, in exchange for higher taxes. Principles had to deviate from money, and we have problems with that. Where is the time that Mr. Stevaert and other members of the socialist family, murder and fire shouted towards the pharmaceutical industry. Now it turns out that they do not see grades in concluding a deal with the same pharmaceutical sector.

I am sorry for my cynicism, Mr. Minister, but you may speak of luck that not all the nice ideas that Mr. Robert Stevaert has raised over the past weeks and months have been concrete. Can you imagine the following. Under the motto “My own pharmaceutical industry first” — who am I to have a problem with that — the idea was launched to exempt the pharmaceutical industry that performs research and development of medicinal products in the home country from the high recovery fees in case of exceeding the pharmaceutical budget. You may speak of luck that in certain departments there are still people who know that Mr Stevaert does not control the file in any way in terms of content, but only plays on the perception.

Can you imagine that Mr. Stevaert had the necessary technical knowledge and was followed in his sweetness of the last months? Then today you would have a major budgetary problem, even ignoring the whole debate about European competition rules. Imagine that Stevaert would be right in this, then tens of millions would pass through your nose. Now it is the pharmaceutical sector that needs to provide additional millions so that you can deliver a closing budget.

I would like to continue, among other things, on the issue of reference refunds. The debate was initiated by your predecessor, Mr Vandenbroucke. We are ready to follow you on this path. However, it would not be appropriate to first provide for an evaluation of the system of reference refunds for medicinal products. Today we will vote on the possibility of expanding the system, but we do not even have a first assessment of the current situation.

Mr. Minister, I remind you of a very good suggestion from the state-general of the Flemish hospitals. They propose that the entire reference refund scheme should not be based on a national Belgian average, but should be brought to the level of the Flemish consumption pattern and the reference refund scheme should be based on it. Mr. Minister, you could recover millions of euros in a very easy way, if one had the courage to concrete some meaningful suggestions.

Mr. Minister, I would also like to say a few words about the famous problem of the care regions. It gives us a very old and unforgettable impression. I described it in the committee as testifying to a far-reaching dirigist approach. It is the PS very old style that we see performing here.

For us, the fundamental problem with the care regions is that at the Flemish level there is indeed such a thing as a decree concerning the first line. Following the insistence of a number of colleagues, you have to answer that there is indeed a procedure at the Arbitration Court. We now say it very clearly and maintain the amendment to the draft law presented here today.

It is quite unlikely, at the time when a procedure is pending at the Arbitration Court, to force the entire arrangement of the care regions, of course something otherwise formulated, at the federal level. However, this is not the case now that an arbitration proceedings are underway. It would have been possible to show some politeness towards the Communities and wait for the judgment of the Arbitration Court, unless of course – which is a constant of these days – the judgments of the Arbitration Court have become completely irrelevant, think of the Brussels-Halle-Vilvoorde dossier.

Mr. Minister, I cannot bypass the problem of heavy technical medicine and the famous management of the PET scans. You are even trying to recover the entire system of control and recognition for a large piece of federal with one of your famous measures. After all, you had said that Flemish savings would be carried out and illegal PET scanners would come out, because PS Minister Demotte would sometimes put order on things and get rid of the PET scanner.

Mr. Minister, it was so striking to me that I would like to remind you for a moment of an answer to a written question from me, which your cabinet formulated. I will quote the answer now. At the end of it, I will ask myself politely if it is permitted that I am very critical on behalf of the VB group and if I can expect from a PS minister, who dares to formulate such a response, that something will change.

Colleagues, I will briefly quote the question concerned and the response of the Cabinet. I refer to the file submitted by the Flemish Association of Physicians; which had demanded that the government would take measures to save. Eventually, the famous PET scandal file has become a symbol file.

In the end, I asked three questions, Mr. Minister. Their

The first — written — question was: "How do you explain the unreasonable difference in the number of PET scans between Flanders and Wallonia?". Second concrete question: "What measures have you already taken to reduce the number of PET scans in Wallonia? If you have not taken action yet, what is the argument for this?” Their

Then began the very nice response. Dear colleagues, I really want to remember none of you because it is very typical of what is happening in this House. Their

"I have the honor to answer the respectable member as follows. The respective member asks me questions about the regional differences in the field of PET scanners. According to the same member, there would be 5 aircraft installed in Flanders and 14 in Wallonia. Consequently, the respectable member asks me how these differences should be explained, what measures were taken to reduce the differences and, if such measures were not taken, what is the reason for this. Their

The program provides for 1 service for each university faculty with a full study program in medicine or that treats exclusively tumors, so 8, and 1 service per full disk of 1,600,000 inhabitants, so 3 services in the Flemish Region and 2 in the Waals Region. Their

According to the information available to us through the Ministers of the Regions, these aircraft are installed in West Flanders, Antwerp and Limburg for the Flemish Region and in Mont-Godinne and Charleroi for the Wallish Region. Taking into account the locations of the university hospitals, this means that there are actually 5 approved PET scanners for the Flemish Region and 4 PET scanners for the Waals Region. I think the distribution is perfectly balanced.” Their

This is stated by the Cabinet of Minister Demotte. “The Wallish and Flemish administrations have not informed us about the existence of other recognised services. If in certain hospitals there are additional non-recognized services of nuclear medicine with a PET scanner, it is the responsibility of the Communities and the Regions to take appropriate measures during the inspections and to inform me if necessary.”

You will indeed say to me, Mr. Minister: “Mr. Bultinck, you don’t understand the weather. I will take the necessary measures in this bill." Their

Mr. Minister, I would say well tried but that you will not be sold to Flemish Interesters anymore. I am afraid if I receive such answers and read from your own cabinet, that I may still — and I will remain polite — question whether or not there is sufficient political courage in a PS-minister to start doing something about this dossier. Allow me, Mr. Minister, in a polite manner to doubt this at least.

The next point I would like to discuss, Mr. Minister, is the whole problem of the formation of hospital associations. You know very well that the hospital landscape in Flanders and Wallonia is fundamentally different. In Flanders, the preponderance of the private initiative, in which the Caritas group controls a large portion of the hospitals, while in Wallonia, the government organizes and manages the hospitals through OCMWs. What do we fix? We can also follow this for a bit and therefore you will also notice that I am actually treating the present bill in a positive critical way. One will now finally remove the famous phrase concerning the “fair distribution across the columns.” We can follow that. We find this indeed a sentence that transcends the current spirit of time. On the other hand, we ask that sufficient attention be paid, Mr. Minister, to the preservation and preservation of pluralism.

The next item, Mr. Minister, is of course the whole problem of the routine operations and a penalty at the time when the reference price is exceeded by 10% instead of the current 20%. I have asked you about this in the committee several times in the past. In fact, it is not more than normal that we go to a single price that becomes the norm for routine operations across the country. We must move towards a system in which the discharges, which we all know now and about which I have indeed interpelled you many times in the past, are eliminated.

Also with regard to the improper use of the emergency cases, we can follow for a part the measures in this bill. I have only two critical comments. Indeed, we must ensure that sufficient attention is given to the social element and that, on the other hand, it is balanced with the abuses. I am actually very pleased, Mr. Minister, that at this very moment colleague Bacquelaine comes to worship us with his presence. This would give me the opportunity to ask colleague Bacquelaine for a moment whether he will later hold a heavy opposition intervention or whether he...

Mr. Bacquelaine will speak after you. You will hear what he says.

Mr. Speaker, I will follow very closely. I try to provoke him for a moment. I know that he usually moves like a Sphinx through this Parliament. I try to provoke him. Colleague Bacquelaine, I would like to know for a moment whether you will now really place your own minister — you know that your days are counted within the majority — under curatele.

I would like to know from you whether or not you believe his figures and, as we could read today in The Time, beams that there is no dirt in the air. Mr. Speaker, I do not notice much body language in Mr. Bacquelaine. I expect to get the answer later. If this later does not succeed, then I will — in order to remain in my role of Vlaams Belanger — again harass him from my bench and chase a member of the MR on the rod for a moment.

Mr. Minister, colleagues, I come to a number of important items that cause irritation between doctors and specialists on the one hand and hospital managers on the other. We have seen the agreement concerning the famous moratorium on honorary wage withdrawals come in part. Of the original intentions of that moratorium, now only a vague year remains. In the end, there are so many exceptions provided where anyone who follows the file a little can ask a lot of questions.

Mr. Minister, a very concrete question. Is it still serious and is it still in line with what was originally agreed with the actors? Is it still reasonable to ultimately maintain a moratorium that will only last a maximum of one year while you know very well that it was a balanced agreement, in particular a moratorium on the withdrawal of medical fees versus the settlement of the entire problem of the underfinancing of the hospitals. You know better than anyone that this job will unfortunately not be completed in a year time. Therefore this clear question. Is this still correct in relation to public opinion, or have dark forces been working and the lobbying of the hospital world has been stronger than that of the hospital doctors?

I come to another concrete question that remains. Over the past few days, we have been able to record a number of excesses. You will know very well that in this file the doctor’s fees are partly included in the package of excesses of the past year. Compared to other surpluses such as the pharmaceutical sector, the surpluses due to the fees are still on track. At the end of the day, the medical fees are exceeded. My concrete question is: will you grant or not grant the index increase promised and agreed with the doctors? This is a very concrete question to which I expect an answer at the end of the debate. Mr. Minister, the next item that I want to cut down for a moment is the whole problem of the cheapest products. You have repeatedly informed the media that in the future the pharmacists — Ms. Detiège may show some interest because it is her professional group; she may even know what it is about — will be very strictly controlled on whether or not to distribute the cheapest product to the patients concerned. Mr. Minister, that is the big story of a system that through Farmanet must provide for the prescription on the name of the substance.

I must honestly tell you that we are waiting for the first royal decrees or legal initiatives. After all, Mr. Minister, I have again looked at the present bill with an enlarged glass. I have found very little about the aforementioned problem. For my part, the whole item of accreditation with the possibility of sanctioning is somewhat different from what is now announced to the pharmacists through the media.

In that regard, I also have very clearly a concrete question: by when will which initiatives be taken concrete or will this plan continue to be stuck with announcements and nothing more than that?

Mr. Speaker, Mr. Minister, I do with your approval an attempt to close slowly.

This is appreciated.

I do not, however, want to do so without being critical — I mean, Mr. Minister — about your famous powers.

I would like to apologize in advance to Mr. Bacquelaine, but I would like to take a moment back to one of the newspaper clips that he may remember in one of his better moments.

Mr. Bacquelaine, I take L'Echo from March 8, 2005 and read a quote from Mr. Bacquelaine: "Les pouvoirs spéciaux de Demotte sont dangereux."

I also look at Mrs. De Block, in better doing in one or another issue of The Doctor's Journal.

Mrs. De Block, I read in it the representation of some medical debate that took place in Flemish-Brabant: "Confidence must be mutual. It is a shame that the minister wants to enforce the health law with powers. In addition, he must use his budget correctly. The budget is stuck in intersection.”

My colleagues, I no longer understand. Mr. Bacquelaine and Mrs. De Block, you will here later, according to the best majority habit, in a moment of complete anamnese, be unconscious and approve extensive powers. I must honestly say that I read the newspaper articles and the medical press very carefully. As a member of the opposition, I feel strengthened. After all, who am I, dead-only Chamber member Koen Bultinck, note bene of the group to which the most sharp eyes go and where the most questions are asked, which is the Flemish Interest Group, to question important statements of two important, eminent colleagues from the majority, when they declare: "Les pouvoirs spéciaux de Demotte sont dangereux."?

I blinked at the moral authority of colleague Bacquelaine. I have no problem with acknowledging that, but the difference, colleague Bacquelaine, is that we will, in principle, vote against. We find what you also thought a thick month ago, in particular that those powers are far too extensive and dangerous. When giving powers to a PS-minister, one must be careful.

The same applies to you, colleague De Block. In that debate you were probably very good and very strong. You said you have principled problems with those powers. Unless later dissident voting behavior is allowed and a number of liberal colleagues are allowed to abstain, as the most courageous act in Parliament, I suspect ...

Mrs. De Block, you have the word for a personal fact.

Mr. Bultinck, if you quote from a debate, you should quote the article in its entirety and say that the quote was a replica. It was a replica to the statement of Mr Ri De Ridder, who belongs to the Cabinet of Minister Demotte for further information. He said that he did not find a reliable opponent as the interlocutor in the general doctors, because they did not interpret unilateral opinions. Therefore, I have said that a dialogue must take place in trust between two parties and that trust must be mutual. You have correctly quoted the rest of the sentence. I don’t say anything about it, even though I’m close to the minister here. You can see that he does not feel uncomfortable with it at all. I would like to say that there should be no dissident voting behavior.

Colleague De Block, can I then assume that you will anticipate for a moment what you are likely to turn down in a few weeks, in particular that you will move back to the opposition banks and that you are already practicing a little and will test a opposite vote or an abstinence to see how it feels? Together with colleague Bacquelaine, you were of the opinion that it is a shame that the minister wants to push this health law with powers through it. Who am I, a simple member of the Chamber, to question that?

I honestly say that we will vote against these powers, because on the basis of strong, intellectual argumentation of two eminent colleagues of the majority, we still find that those powers are far too extensive. And that’s the difference between you and us: we still find that after a month. A month later, you turn the Kazakh again.

Mr. Speaker, Mr. Minister, I am going around. This is a bill of the missed opportunity. In the crisis situation we are in, we have not received a fundamental debate about the organization of healthcare, nor about the element of financing.

In the end, we also continue to push in the margin with this bill, it remains a budgetary document, it remains a far too extensive mandate. Our group is very clear. We cannot support this. We will vote in principle against it until the whole organization of health care in this country is seriously redirected and, in our case, transferred to the Communities.

Mr. Bultinck, you spoke for 38 minutes, but this is also an important topic. I have no problem with that.

I will now give the floor to Mr. Bacquelaine; he will be followed by Mrs. Detiège who will be brief. Understanding the obligations of Mr. Mayor, I will see if I will be able to give him the floor around 15.45 or 17.00. by

I promised several group leaders not to vote before 18:00

I think we can vote already at 16 o’clock.

The word is for mr. Bacquelaine in the general discussion of this project.

Mr. Speaker, Mr. Minister, dear colleagues, we are addressing this bill as part of our philosophy with regard to the healthcare sector.

I would like to recall the guidelines that, for us, are intangible and must persist, before coming to the text itself and to the implications of this bill on the health sector.

In fact, we would like to analyze all the texts relating to this sector, in the light of the specificities of the healthcare system that we know in Belgium and which is, I like to recall, a system performing in the sense that it meets the expectations of the population in general, with a will to ensure a very high accessibility to quality care – an accessibility to care that makes sense only if it is quality care – for all, regardless of the socio-professional, economic and financial status of individuals, but in a spirit that allows healthcare providers to provide the services that they consciously deem necessary. I used to say that access to care would be futile if it was only access to care providers who would be required to provide less quality care or that they would conscientiously consider insufficient.

The specificity of the Belgian system is precisely that healthcare providers have the opportunity to develop quality action towards patients. The free choice of patients, the therapeutic and diagnostic freedom of doctors, the conventional method of consultation that we know in Belgium make our system widely envious and can, it seems to me, serve as a model for the European health system that we call our wishes.

I examined the draft health law on the basis of its compatibility with the different specificities of the Belgian health system, namely, accessibility for all, equity in financing, efficiency – that is, the quality/price ratio – free choice, freedom and consultation.

We consider it essential that a budget of such importance is not only the subject of consultation with all relevant sectors, but also the subject of particular attention in relation to the contribution of the citizens of that country. The healthcare budget is one of the most important budgets of the state. It is quite logical that from the moment that this budget has such importance, those who are responsible for it, i.e. governments and parliaments, ensure a rational, optimal use of the resources that are made available to them to carry out this health policy. There should not be any suspicion that the authorities of this country are using the healthcare budget in a questionable way. We have an extremely important mission and we must ensure that the budget dedicated to people’s well-being and health is effectively used well.

As for the bill itself, it includes a series of useful and necessary measures because a good use of health budgets requires that we have at our disposal, and at the disposal of the minister and the government, tools that allow at any time to correct the shot in case of deviations or deviations so that the budget is, again, used optimally.

I was among those who regretted, in the fall of 2004, when drawing up the 2005 budget, that we could not have certain figures on health care. We can be pleased that in the end, the deficit of 2004 is "only" of 513 million instead of the 634 million euros announced. It must be remembered that during last fall, we evolved between figures of 300 million deficit at some times and 900 million at other times. We were in full uncertainty about the budget figures. We prepared a 2005 budget based on a figure of which we obviously did not know the relevance or certainty. This inaccuracy, in a budget as large as that of health care, is not admissible. We have the duty to demand from the INAMI that it provides us, and that it provides the Minister in charge of the sector, more accurate, more realistic figures that suffer less contestation or contradictions.

In our time, any company provides bilateral and financial statements of much greater accuracy, whether it is SMEs or large companies, as we are facing a huge budget that should not suffer from such inaccuracies. Therefore, we strongly demand that the government can have real-time figures on the evolution of the healthcare budget spending. We are told that this is difficult due to bills that do not always take place at the same time. What does it matter! What is exactly abnormal is that the invoicing is made at the will of the actors or insurance agencies. We need to evolve into a system that allows for greater precision, greater relevance in the analysis of budgets. We, patients and taxpayers, deserve greater rigour in analyzing the evolution of healthcare budget spending.

I would like to point out Mr. Bacquelaine that his remarks meet exactly those we held at the time of drafting the budget.

Yes, absolutely absolutely !

This is exactly the request that the government itself made in November last year. This is exactly the answer that INAMI provided in its report to the Minister of Social Affairs, highlighting the need for a new procedure for early detection of risks of exceeding the overall budgetary objective and the partial budgetary objective. This is the exact request of the government. In this regard, there is in principle no subject to controversy between us, since we agree on this point.

However, your statement to the newspaper "Le Soir" and those of this weekend were visibly more political, more controversial. This makes no sense since we are asking for exactly the same thing! This is not under the supervision of the Minister. This is a control of the department, as other departments must be put under control. by Mr. Vande Lanotte proposes to put, permanently, under control the Department of Finance, to see if the revenues correspond to our needs and what the department actually does. On all these points, I interrupt you because I do not see where the controversy is.

I will explain it to you. I would like to say firstly that I have never heard a member of the Reform Movement or a liberal pronounce the word "tutelle". The only people who have spoken of custody are the Socialists. I am surprised by this drift in relation to the reading of the statements made by one and another. I myself, and the chairman of my party, have never talked about custody. This has never been pronounced, and I do not know where you read it. If you can show me where you have "read" this way of perceiving things, I would be happy to see it, because it does not appear in "Le Soir", nor in "La Libre Belgique", nor in "South Press".

It was a television intervention. But it was too laconic because it was on television.

It seems somewhat strange to me and it leads me to think that if you think you’ve read it, a psychoanalytic analysis of your behavior would allow me to think that you would have desired it actually being said.

of which act. I think the statement of the leader of the group MR of the House of Representatives ends the controversy. There is no question of the Minister, we agree.

Mr. Mayeur, we think

That a budget as large as that of healthcare and a sector as large as that must be the subject of the government as a whole, because all government partners are concerned, of a monitoring and analysis that cannot be limited to the conventional budgetary control.

Mr. Speaker, in relation to the text of the law that we are studying today — since everything else might appear to be very speculative — it is true that this department is not an ordinary department. As I explained earlier, one cannot control a healthcare budget in the same way as one simply controls a budget with predetermined appropriations. Here, an extremely complex set of factors is involved. The method that is also used in the authorization that is discussed here takes into account the governmental collegiality. I will remind you that these are deliberate resolutions in the Council of Ministers; therefore the technique itself provides for this device, but with a close exception: what still exists today around the Kiwi model, because in this case, it is simple resolutions.

I would like to add the example of the municipality, since I am a municipalist. In communes, when a sector of activity requires a significant allocation in terms of resources, I require that the subject comes flowing in college and is not reserved for scabinal management, which I think is normal.

You have addressed the subject of tax revenues yourself; it is true that tax revenues and health expenses do not always match the forecasts. Overall, both are higher than expected. It cannot be denied. Fortunately, tax revenues are higher than expected because this allows, among other things, to pay for healthcare expenses through alternative financing. The analysis of tax revenues is constantly monitored by our government, which we find quite legitimate.

Here is what we specified at the beginning of the week, thus showing our interest in the subject. We have firmly defended the growth standard of 4.5% + inflation because we actually believe that health spending deserves a favorable treatment compared to the overall growth of spending in this country. This concerns the needs and everyday life of people. This ⁇ high growth legitimates and requires a ⁇ sharp monitoring of the development of budgets. This is the explanation for our reminder of the need for the government to constantly evaluate the evolution of health spending. Some have wanted to see something else, I regret it. On our part, we simply wanted to recall what seemed to us to be obvious.

The health bill, more specifically, can be analyzed in various ways. On the one hand, by what it contains, on the other hand, by what it should have contained. Let me start with what it contains. It contains, in my opinion, useful and necessary tools to control, in the most efficient way, the use of allocations made available to the sector. The chapter on medicines seems perfectly justified since, out of the 513 million budget surpluses in 2004, 384 million (practically 80%), concern the pharmaceutical sector.

We wanted to make compatible – this was our permanent vision during the review of this text – the control of the drug budget with the need to avoid the development of a two-speed medicine while ensuring that access to innovative and high-performance drugs is ⁇ ined and guaranteed for everyone. This was our leitmotiv in relation to this project and the articles about the drug.

This is why we wanted the tender to be for non-patent medicines as it seemed important to us not to mortgage the provision of innovative and performing medicines to patients in Belgium that the pharmaceutical industry develops and researches in our country where it represents 26,000 jobs. The sector is important and, I repeat, it seemed necessary for us not to mortgage its possibility of developing innovative molecules in our country, putting them on the market and making therapeutic services useful in this regard. In my opinion, the pharmaceutical sector has been considered effectively and realistically.

With regard to hospital collaboration, Mr. Minister, we are quite pleased with the good development of the case of inter-hospital collaboration. We will be with you to make sure that we can advance in terms of collaboration between hospitals so that heavy and expensive equipment is used in the most rational way possible, ignoring an old-diet type polarization that does not bring much to the patient himself who, by the way, does not feel concerned about the origin of such or such equipment but wants to benefit from a performance equipment; in fact, at the limit, the location of the equipment is of little importance to the patient as long as this equipment exists in his region. This inter-hospital collaboration must be developed. The health bill gives the necessary authorization and tools to do so.

As for the programming of PET-scans, I draw your attention to the need – and the bill responds to it – to review it more accurately. However, we tell you from the beginning that, if we are obviously aware of the necessity of this programming, it must be done in a balanced way.

With regard to the moratorium on the collection of fees by hospitals, I admit to you a certain disappointment with regard to its evolution. I have always considered that the modalities of financing hospitals favour a certain type of overconsumption in our country and that the fact that hospitals can subtract "parts" of medical fees for general hospital management was a way to encourage overconsumption. So the moratorium was a good idea, even though it wasn’t enough. It will probably be necessary to go further, to modify article 140 on hospitals to ensure that the financing of hospitals is not necessarily dependent on the production of medical records.

I am personally in favour of a new system of financing of hospitals that makes very clear the difference between the financing of medical activity and that of hospital logistics. These are two completely different aspects and the fact of relying on the production of medical documents to finance hospital maintenance and investment does not seem to me to be wise. We therefore call for further progress in the collection of fees by hospital managers and for a more radical separation between the production of medical records and the need for hospital financing.

One aspect I still have to address, and I look forward to, is the new measures concerning the Special Solidarity Fund. Our health system is based on solidarity — and fortunately. We have always considered that solidarity should be total when it concerns tragic events, including families facing situations of extreme gravity, such as a child’s cancer or chronic diseases that lead to very long work disabilities. There is in these matters the need to develop even greater solidarities. I look forward to seeing the Special Solidarity Fund enable greater scale in the handling of extremely serious and painful societal problems.

As I said, there is also something that is not included in the health bill. I have to admit that I am still hungry in some areas. We are morally obliged to make the best use of the money that the taxpayers put at our disposal to care for people — because, to speak very simply, that is exactly what it is about. by

It seems to me that in this area, all the possibilities have not yet been exploited. I think we need to be more attentive to the phenomena that still cause unjustified consumption of care.

Mr. Minister, I am concerned that this project on the responsibility without fault, on the medical area does not advance further. Certainly, there are still some difficult problems to resolve: how a compensation fund is financed, the double judicial and insurance path, etc. But great men are recognized for their ability to provide solutions to difficult problems. I think this question needs to be resolved someday. Defence medicine is expensive and is likely to become even more expensive. I try to make you attentive and sensitive to this issue so that we can move forward on this subject.

There are still ideological taboos that lead to excess spending. I think of medical houses. They say they have a social function. Having practiced general medicine for a very long time in a village, in a municipality, I know that this social function is fulfilled in a quite sensible way by the independent providers who have never refused to treat anyone.

However, I also know that a medical home is much more expensive than an independent practice. A patient registered in a medical home costs, in terms of general medicine, about 120 euros per year, while in the independent sector, it costs only 64 euros per year. There is therefore an unacceptable disproportion that is found in the care of physiotherapy, in the care of nurses, and that remains in our system only by ideology. I see no other explanation. One day we will need to have the courage to set the accounts of these two systems flat to determine which is most financially performing.

Just recently, in my general answer, I will return to other aspects; I do not want to be too long but I just allow myself to give a precision. I had already heard in the previous general debate, a number of information on the numbers, so I will propose to Mr. Bacquelaine, to be very concrete, that we have a discussion in commission on the various points. But I also would not want to be obscured in caricatures in both directions. If you take, for example, solo medical practice and if you think of specialized medicine, there are specialized doctors who practice in the hospital structure, and who also refer to their solo practice. If we calculate the costs, we may be surprised here too. I think this is a very good discussion that we could have together in the committee.

I take note of it. A third element that will one day have to be actively addressed: the administrative burden that is growing in the healthcare sector. This administrative burden, in the end, is expensive. Service providers, whether they are physicians, nurses, fitness therapists, social workers, and all functions that work in hospitals, spend more and more time filling out papers. And while they fill out papers, not only are they paid, but in addition they do not necessarily take care of patients. There is here, from the point of view of the rationality of useful time, an examination to be done to return to something a little less Kafkaic. It is known that, in the debate on the agreement in the non-market, several hospital actors have highlighted the weight of the administrative burdens that are imposed on them, and there is undoubtedly a necessary flat-fitting of what I call the "normative rain", which does not necessarily bring an added value in terms of health care, but which, on the other hand, monopolises time that could be spent more usefully elsewhere.

Per ⁇ we should also look at our hospital park. I talked about the inter-hospital collaboration, it is a good thing, but it remains that in our country, the number of hospital beds remains above the European average. This debate must also take place. We are 20% above the European average in terms of hospital beds. Hospital beds, regardless of the care that is provided in the hospital structure, cost before even being occupied. It would be useful to look at this problem of hospital plethora, which ⁇ costs money and amputates the healthcare budget that could undoubtedly be better used in this area.

Finally, I would like to ask the question of the ticket moderators. The ticket moderator seems to me to have its name: it must moderate. Currently, however, it seems to me that there are a number of systems that allow to bypass the moderating character of patient participation and which would undoubtedly deserve to be questioned.

If the moderator ticket was created, it is precisely to make the patient accountable in relation to health expenses. You will tell me that indeed a number of patients do not have the ability to personally intervene in the care they need. I am aware of it. This is also the reason why we have agreed to create the maximum to be billed. This seems to us a guarantee that allows every patient to benefit from quality care while preserving accessibility. It is true that it is necessary, at some point, to advance funds, but you know like me that, for people who are actually in a poor situation, the third-paying is a system that is applicable, which is not always, but which could be. Most doctors are not opposed, on the contrary, to apply the third-paying system for the most disadvantaged people in order to prevent them from advancing moderator tickets or the payment of fees in their entirety.

I think that the moderator ticket should be required and, for most of them, not reinsuranceable so that they keep their effective moderator poster in front-line care and health care in general.

In conclusion, Mr. Minister, we consider that the health law that will be voted today gives you and gives the government the useful and necessary tools to ensure control of the healthcare budget. It will need to be used intelligently – but we have no doubt that it will be. It will be used in our consultation system. This system is useful and allows all health care actors to feel concerned. Therefore, the maintenance of the concertation seems to us useful and necessary.

I would also like to emphasize one element that does not clearly appear in the debate and that is the necessary attractiveness of health professions in our country. I have some concerns when I see doctors leaving the country. We know the phenomenon in scientific research: many researchers leave and do not return. It is good that they go to see elsewhere but it would be good if they come back from time to time to bring us the fruit of their experiences. In healthcare professions, we are increasingly aware of this phenomenon. So we must ask ourselves questions: are they leaving for strictly financial or monetary reasons? I do not believe it. I think the revaluation we participated in was useful and ⁇ allowed to make the intellectual act more attractive in our country.

The administrative burden, of which I spoke just recently, is ⁇ the cause of a certain leak of health professionals who feel that our system is becoming too constraining and that, in other countries, the exercise of their profession focuses more on the very reason of their vocation, that is, to care for people. I have some concerns when I find that more and more doctors decide to leave, depending on their linguistic affiliation, in France, in the Netherlands, etc. to exercise their profession. The same applies to physicians and nurses. We must ensure that our system, our health care organization allow vocations to express themselves in our country and give people the urge to practice medicine, physiotherapy or nursing art in Belgium, under conditions that they find acceptable in terms of social status, financial status, family life and the organization of their personal life but also according to the administrative burdens imposed on them by the system.

This is probably an area that will be a challenge in the coming months. We often hear about the risk of shortages. But we know that this shortage exists only because of the disengagement that could suffer in the exercise of the professions and not the actual number of people with a degree from our universities or our major schools. There are enough. Even in the nursing sector, where we often talk about shortages, it is known that many graduate nurses and nurses prefer not to work in the current system, considering it too complicated, too heavy, too compelling.

The problem of the attractiveness of professions in our country should deserve all our attention. We must ensure the survival of an effective, accessible healthcare system that gives all guarantees to the patient to find the best care in our country.

I wish you a good implementation of the bill that we are going to vote today. I hope that we can together, in a year, say that the 2005 healthcare budget has been perfectly executed and that the forecasts have been met.

Mr. Speaker, Mr. Minister, colleagues, in the last few weeks, the functioning of the Public Health Committee was under the sign of the Health Act submitted by Minister Demotte.

The committee needed more than one session to discuss the law. There was even a nightly session needed to approve the new health law. It was clear from the length of the discussions and the number of amendments by the various parties that this was a crucial event. I mean by this that a number of points in the Health Act will have a serious impact on health care. I was therefore pleased that all committee members have committed themselves to make the law a workable instrument, each based on their own expertise and good intentions.

Contrary to what the health specialist Mr. Goutry said two weeks ago in De Morgen, I find that the minister does not choose eggs for his money. In my eyes and in those of a number of specialists who have followed the dossier closely, the minister has not gone flat on his belly. As far as I know, he is absolutely not a dry fig. Those who have followed the committee will know what I mean. I do not know whether this terminology should be used in a plenary session, but at the end of the day I was surprised by the figurative statements made during the nightly sessions.

Important for sp.a is that the new law provides for the application of the market search for medicinal products. The kiwi idea launched by sp.a. chairman Steve Stevaert is simple. The government asks the pharmaceutical companies to make an offer for a particular medicinal product and on the basis of those offers it selects a number of products with the best price-quality ratio. In practice, it will be the Pharmaceutical Compensation Commission (CTG) who will review the refund for groups of medicinal products used for an identical or similar indication depending on the leaflet. Only the medicines that are still subject to patent are excluded from this market search.

This system is a real win-win situation. The patient pays a lot less for his medicines and the government saves in health insurance. As in New Zealand, the kiwi system will not apply to new innovative medicines. I explain the nuance here. These are medicines with a high or real therapeutic added value. The CTG will, as it has done so far, attempt to reimburse the new medicines taking into account the price-quality ratio, the severity of the disease and the sales volume.

It would be useful to schedule a hearing with the New Zealand state-owned company Pharmac to ask how they work. Also in this regard, the New Zealanders appear to have a well-founded expertise.

I come to a second and very important point for me. The battle with the neppatents can finally be started. These are drugs that were marketed by the firms for the same indication, but without a therapeutic added value, and which are still significantly more expensive than their predecessors whose patent is threatening to expire. In other words, they were only marketed to obtain a new patent. Therefore, new measures are being taken. For example, it provides for a study by the CTG to demonstrate which specialties have or do not have a therapeutic added value, rather than be supposedly innovative. It was also legally stipulated that the results of the investigation will be submitted both to the Minister and to the Parliament. On the basis of the report of the CTG, the Minister or the CTG itself may initiate a procedure for changing the modalities of remuneration. In other words, the neppatents can be addressed. The fight against specialty types is fundamental to ensure that the available resources can be fully used to compensate for truly innovative specialties.

A third important point is another aspect of the extension of the reference refund. The only criterion so far was that the drug must be identical to the same. For example, if it was a tablet, one could compare a tablet with a tablet. In practice, it will now be like in Germany: for example, pills, suppositories and injection forms will also be included in the reference refund. This measure will result in savings of EUR 43 million.

Article 58 of the Health Act is also important. A very small sentence is added to the existing legislation on the refund of medicines. It is a small sentence, but with a lot of impact. From now on, the Minister may require companies to remain in the refund system for certain specialties. For example, think of the whole heisa around the contraceptive or the pill.

Mr. Minister, colleagues, I can only state that after a hard and tired consultation now the best and most feasible health law is being proposed. The Sp.a has already been able to introduce very important and innovative measures that contribute to better control of health care without having to compromise quality – and that is very important.

Mr. Minister, as you will have understood from my speech, the SPA supports your proposed bill. I am also confident that you will regularly inform us in the Committee on Public Health of the state of affairs in the Committee on Repayment of Medicines. This committee is most closely involved and will have to undergo a very important change.

Will the CTG have to know a thorough reform? Will the market survey procedure that is now launched need to be adjusted and even expanded at a later stage? An evaluation here is ⁇ in place, because the Belgian kiwi model is an important tool for controlling the prices of medicines and must absolutely be able to succeed at 100%.

Mr. Speaker, Mr. Minister, dear colleagues, we must start with the problem of the budget and the growth standard. It was set at 4.5% excluding inflation and we look forward to it. It happens that the natural trend of expenditure growth is likely to be higher than the fixed standard: today we are talking about 9% growth. If we look at the situation of the 2004 account compared to the budget, we are indeed growing — and a significant growth. This requires control of healthcare spending. We have discussed this before and we agree with this idea. On condition of course not to touch the accessibility of care for patients, the quality of medicine, the basic principle of our system which is that of free choice.

It is extraordinary to be in a system of free choice with the social character of accessibility and maximum social coverage – 98 or 99% of mutualist coverage in this country, which is extraordinary – in a concerted system and also to face a difficulty in controlling spending regardless of the public authority. This is due to the diversity of actors. These different actors, who agree when they are organised collectively on the budgetary objectives set, are unable to stick to them in the individual practice and are facing particular difficulties that cause disruptions despite all, or are facing an increase in demand.

When you look at the figures of 2004 and find that three times 50 million, approximately, are spent on fees, the MAF (maximum to charge) and the care of the elderly, you can conclude that these amounts are related to the needs of the population. They correspond to a medical consumption, to a use of the system that is probably related to the real needs of the population. We can then ask ourselves the following question in this sense: given these excesses, are the 4,5% sufficient? I am not inclined to say that the numbers are there and that they must be accepted. Of course, they need to be checked and verified, but they deserve a thorough examination. It is not necessary to struggle with the standard if it proves insufficient because the budget that we had initially set was insufficient. By the way, I had already made this observation during the examination of the budget: one can set a limited growth standard but if the starting budget is not adequate, one will necessarily very quickly exceed the growth standard.

Of course, we are in favor of spending control. I even recalled the request of the government and the minister himself in November, as well as the INAMI response in this regard: the need for more appropriate control of spending in the bill we are examining. We obviously agree with this idea. Only, and this is political, I also said that revenue should be controlled within the government. Contrary to what Mr. Bacquelaine that I interrupted just recently about this, revenues are not always undervalued, since we have overvalued what the DLU was going to report, the repatriation of money placed abroad.

This is far below the forecasts announced by the Minister. We did not decide to put him under custody. He would not have accepted such a measure.

I noted, regarding the bill examined, positive aspects concerning patients, including positive measures through the Special Solidarity Fund. Some treatments are extremely expensive. However, the Special Solidarity Fund will intervene, among other things, in supporting innovative medical techniques that are not yet included in the nomenclature of reimbursable benefits. This positive aspect for patients should be emphasized.

There is also the easing of the rules for access to the Special Solidarity Fund for minors under the age of 19. Taking care of all their medical care seems to me to be an extremely positive element for patients and that should be ⁇ as part of this bill.

The rest of the measures are measures to control and strengthen the principles of accountability, including actors.

It is the role of public authorities to remind the various actors of the sector of their responsibilities. Responsibility mechanisms must be strengthened. The government’s option is to work according to the “all in” package method, but with caution because variations must be taken into account as certain specific pathologies. We obviously agree on this because it is by empowering the actors that we will manage the expenses better.

Certainly, actors can engage collectively, but sometimes it is at the individual level that difficulties arise. There is also this willingness to individually hold the stakeholders responsible for the medical-mutuellist conventions in order to encourage doctors to therapeutic practices more respectful of public finances, in particular through accreditation. This measure goes in the direction of our desire for increased control, including on the ground, of the economic measures that must be taken and of limiting spending within the budgetary resources that we have at our disposal.

The changes made to the Hospital Law satisfy us in a large part, such as, for example, the notion of care pools and the idea that one can, in a defined geographical area, make the hospital institutions work together in such a way as to avoid unnecessary spending in the same care pool and for the same type of population. This is an important advance. The fact that from now on the associations of hospitals that will be allocated their own budgets will be reviewed within this bill seems to us to go in the direction of what is desirable, of a rationalization of the supply on the ground without altering the supply necessary to meet the needs of the population.

Mr. Minister, as I said in the committee, a measure poses difficulties to me on a personal level. This is the one that aims to prohibit the claim, in principle, of a flat-rate contribution in emergency services, except through the framework of a moderator ticket of 9.50 euros or 4.75 euros if one is in a special regime.

I remain convinced that this is not a good measure. Together with my colleague Marie-Claire Lambert, I submitted a bill to prohibit purely and simply the tax on access to emergencies. I acknowledge that the bill sets a number of limits and will therefore not necessarily sanction all patients who will appear to the emergencies, as Minister Vandenbroucke decided during the previous legislature. This measure is therefore less negative and better preserves patients, but I would have wanted to be more inspired by the experiments conducted on the ground, in particular in a Brussels hospital that I know well but also in other hospitals, in Charleroi and elsewhere in the country.

There are field experiments with general practitioners who make a priority sort in access to specialized emergencies. This works well. This has a positive impact on the consultation of specialized emergencies since the intervention of this general doctor at the emergency door allowed a 30% reduction in the consultation of specialized emergencies. This seems to me to be a measure, in essence, structurally more interesting for the system, given that it will reduce the overall costs due to a less recourse to specialists. This system seems to me better than imposing a brake, even psychological, on access to emergencies through a financial measure, even though I acknowledge that the four measures included in the bill will limit "the break".

Nevertheless, this is a bad signal, especially since this measure was taken by some hospitals not to limit access to emergencies but to find a supplementary way to finance the hospital given its structural underfinancing. This is the phrase that, from now on, one goes out systematically when one needs money and that one wants to invent a measure. So, very objectively, if some hospitals had applied a tax of 15 euros or 12,5 euros as Mr. had proposed. Vandenbroucke or even other higher amounts that have been imagined for administrative and other expenses to the accessibility of emergencies, this is not at all to limit access to emergencies, it is to reflux the hospital cash. This is not acceptable. We will need to quickly look at the alternative experiments that have been conducted and how these experiments can be extended to all the hospital structures and emergency devices implemented in our country’s hospitals.

I come to the moratorium on the agreements signed between the manager and the medical council with regard to fees. I have heard the comments of Mr. Bacquelaine about fees. Sometimes I hear doctors say "the fees belong to doctors!" Yes, except that within the hospital, the doctor also decides, with the manager, the size of the infrastructure, the investments to be made, the expenses to be consented for the medical device, etc. Obviously, the fee occurs at all these levels because, of course, the doctor is associated with management. Let's be careful: all revenues that enter the hospital must, in one way or another, contribute to the operation of the hospital, the institution.

I agree with this moratorium, but it should not lead us to a measure, project or proposal aimed at prohibiting the manager from collecting anything from the fees practiced by doctors in the hospital. This is neither acceptable nor fair. This does not seem right to me in terms of the management of healthcare institutions and those who practice them, at the expense imposed on the community and that they must, in part, contribute to assume too.

The royal decrees that had been cancelled by the State Council and which set the standards of authorization and the rules regarding the maximum number of medical imaging services, MRIs and PET-scans, are finally reintroduced into the law. This is a good thing for us. Programming criteria must be met. It is necessary to fight against the development of these heavy equipment, “pirates” which, in the end, also cost the community, without necessarily bringing a plus to the patience. We cannot accept these methods that have been practiced in many hospitals. A program must be set and enforced; otherwise, the healthcare spending of this country will explode even more.

Some mentioned the “special powers” granted to the King and ministers in certain matters. First, the expression "special powers" seems to me a bit excessive; or one has the short memory of the "Martens" years of special powers, numbered royal decrees, etc. We have to be honest, we are far from it. It is simply about allowing ministers to take measures for a specified time — that is, for the rest of the year 2005 — in order to control spending: everyone here claims and demands that this be the priority of the government.

We are not going to discuss here the control of expenditure, it is necessary that an authority be empowered to take action. There is a list of points and gaps on which the Minister can act. It is limited in time, but it actually deals with the essence of what can bring economic measures. One cannot be schizophrenic, both asking the minister to take measures and not giving him the means, as is practiced in foreign policy. I think of an example that I know very well. One must be prudent, one cannot impose and claim things which then one does not wish to be applied, because one does not give the one who wants to realize them the means to do so.

Mr. Mayeur, at this point I do not accept the criticism that is constantly given here. The Minister says that we have sophistic reasoning, in the sense that we demand that the budget be properly managed, but are against the measures that are intended to be taken for that purpose. No, this is not a political game. What we say is purely substantial. For years, we have been saying: be careful! Therefore, we have also established a growth standard. We have been warning for years that the budget is constantly being exceeded. Furthermore, we are getting more and more the impression that we do not get a grip on it and do not know exactly where there are excesses due to which mechanism and so on. We are constantly advocating for accountability. Their

One must be able to give a much more fine picture of everything by gathering data and being able to record everything correctly, so that one can see well where there is an excess, how much it amounts and how then one can take very focused or focused action. You do the opposite. In fact, you say that you do not see it anymore, that we are facing a big problem but do not know where it is. You ask for a super-canon—a mandate—and you will shoot at everything that moves. What will be the consequence? and linear measures. You will not hit who should be hit, you will hit everyone a little and hunt everyone against you in the armor. It will be one-time, for a short time, but after the mandate you will again face the current problems! That is the thorough criticism that we have on the technique of the powers in health insurance. This is not an exceptional condition; it has existed for years. This is not a situation in which one needs special powers because one must be able to regulate something. No, this is powerlessness. Power is powerlessness in this case.

I believe in the intellectual honesty of Mr. President. Goutry, but very honestly, I really think it’s the opposite that happens. We realize that we have mechanisms that exist, and yet we have a breakdown. Beyond even the polemics about the numbers as we know them in the months of September and October 2004, we have a situation of 513 million exceeding for 2004. That’s less than I thought, I know. However, there is a surpass. However, measures should be taken against these excesses. These surpasses are there, we know where they are, so we know what we can do. Is it scandalous to say that since one knows what is happening, that one knows what one can do, it is necessary for this to empower an authority to take the measures within a specified period? Is it scandalous? I cannot imagine it. This is different from what we knew at a time when the special powers that were imposed upon us were draconian measures that affected people, antisocial measures. We are not in this situation at all. Current measures are limited, even though, in essence, no one here is in favor of special powers. It is not about that.

Here, we know what is happening, we know the situation, we know what actions can be taken. Very sincerely, I do not feel bad about the authorization that is given to the King and therefore to the Minister to act as it should, for a specified time, on a specified list of subjects. Furthermore, I would tell you that when we make the balance sheet of 2005 in a year, if the measures have not been taken while we have authorized the King, and therefore the Minister, to take the measures, then we will have to question the mechanism in question and the other mechanisms. Is the mechanism of coordination, of committees in which we operate relevant when urgent measures need to be taken and when we face difficulties? Per ⁇ then we need to question the system itself. I see that there are those who smile, we will do so, without privatizing the system, without questioning its essential principles, that is, accessibility to care, consultation with the actors, etc. I will make a meeting in a year, when the measures are taken.

When it comes to drugs, this is the other neuralgic point that makes the budget explode. We are at over 300 million additional consumption. If we do not take action now, we are already announcing, proportionally, exceeds in the same order for the first quarter of 2005. We cannot keep our arms flat, we must take measures in the field of medicines.

Kiwi, mini kiwi or not kiwi? That is the question! First of all, the kiwi model is not “our” model. This is the New Zealand model in a particular health care regime that has nothing to do with ours. by

So, I suggest the “radis” model, which would suit us better.

It is more red.

It is also more red.

But it’s white inside, and it’s very close to the butter plate!

But this is a little bit crazy, Mr. Speaker. And it’s near the butter plate.

The model that we can impose in our system, namely a call to public procurement with a competition of firms and a possibility to play at the same time on the mass and on the prices of medicines so that they are cheaper for the system and the consumer, is it not what is imposed on public authorities in all other matters? We were talking about a municipality; I am also a municipalist. I can't order the slightest real estate works at home if I don't have a public procurement. I am forced to go through there. And it is not always very effective, especially in terms of timing. But this is another debate. Nevertheless it works. In all municipalities, public authorities are obliged to work this way.

In the pharmaceutical sector, can we not act in the same way when we are facing such budgetary explosions? and yes. In my opinion, everyone is now convinced by the principle. Should it be extended to all medicines? No, we do not agree. The liberals did not immediately want to include patented medicines under this system. For other drugs – the “me too,” for example – we agree on the limitations. This is still a positive and important measure, because it is fake innovators.

There is a difference between products that are patented and those that are no longer. In essence, it is aimed at what you say: if it serves the interests of Belgian research and economy, we should not take measures that put them at risk. I agree with this and I do not see who would be against it. We are clearly in favor of advanced research. And in this area, our country makes its contribution. But this is provided, of course, that these are innovative therapies, innovative products that add value to the system. If it comes to supporting the research and production of molecules that already exist, but in another form, it has no interest: it costs and it brings nothing. I am therefore not convinced that these new patents bring added value to medicine and health care.

Therefore, yesterday we tried again, through an amendment, not by definition and in advance, to exclude all products that are still under patent from a market search. Now they do it. Now it is said that all stamped products are excluded from the market search. Well, among those stamped products there are also "me-too's" that have been granted a patent. You say it yourself. There are many false innovations that have also been patented. They remain out of shooting. Nothing can be done about this. They were left out.

What is a me-too?

and a neppatent. Can I take a moment? One must distinguish from medicines that are indeed truly innovative. It is important that these products can be marketed and have patent protection. On the other hand, there are products that have no therapeutic added value and therefore actually bypass the law a little to get a patent. That is where it revolves. Their

The problem is then very often when a new product comes into the market with what is actually a neppatent they suddenly increase their price enormously. It is there, Mr. Goutry, that the CTG will have the permission... I think that’s good because they have specialists in the matter, the minister, for example, should not do so. It will be the CTG itself who will judge whether or not it is a real therapeutic added value. This is fundamental in this debate.

I would like to

There is no ambiguity on this subject.

1 of 1. With regard to the debate on the “me too” we keep, in the text of the law, a tool that allows to identify them — a period of one year is granted to the CRM to work on this matter — and to make proposals.

In addition, the precise arrangements of the text also give the possibility of simplifying the procedures for group revisions. You put both together and you understand that there is a structural vision.

2 of 2. I do not want to argue. I would like Mr. Goutry explains why he filed an amendment to patent drugs without any distinction.

I return to my reasoning. On the general principle of bidding, finally, today, almost everyone is convinced. The problem is at the limit. I am convinced that we will cross the next limit when we are again faced with budgetary problems, excesses and explosions in the pharmaceutical sector. We will inevitably move towards this stage. We have already crossed one. Is it a retreat? I believe that, in view of the previous situation, we have made good progress. Now it will be necessary to measure the effectiveness of the devices implemented and see how the system can be gradually expanded.

But I am convinced that we have put in place a process that will gradually allow us to significantly better control the cost of medicines without necessarily obeying the research capacity, the economic development of this sector in our country. So it seems to me that our choice is reasonable from this point of view and goes in the direction of what was desired. It is true that the initial intention of the government was, in my opinion, symbolically preferable. However, if you scroll through the original text of the project, you will notice that if it was symbolically better, it was impractical. Indeed, two lectures were needed in the Council of Ministers, a socio-economic analysis of the sector and the medicine, etc. before you can make a decision on the patented products. Finally, there is a simpler system in which the minister is empowered by simple royal decree to take action. We have not lost the change. On the contrary! The measure may be less symbolic but more effective and that’s what matters for us.

I will return to this point recently, but I would like to express myself a moment on the issue of kiwi, not kiwi or half-kiwi. I cannot accept that this issue is discussed without note or budget data. I agree to say, Mr. Minister, that a partial kiwi constitutes an advance. This may be a first step. Maybe tomorrow we will have a full kiwi. But I cannot admit that we are first submitted to a complete project and that after we have noticed certain limits, we decide to withdraw certain patented medicines instead of making improvements.

It is unacceptable that we have refused to seriously examine yesterday — I allow myself to say it — an amendment that I submitted and that Mr. Goutry argued, which aimed to re-include patented drugs but in a more nuanced way than it was envisaged in your original project and that all this discussion takes place without budget projections.

We know since Monday, Mr. Mayeur recalled that in the drain—because we must call things by their name—of the 2004 budget, the share of medicines has increased and now accounts for 72% of the drain, while the share of medicines in the healthcare budget is only 19%. Why is a tender withdrawn, submitted, partially or not, without any budget projections? This is something I cannot imagine. I am convinced that you will have to use special powers and, contrary to what was originally thought, the health law will not be sufficient, by itself, to allow the regaining control of the healthcare budget.

It is not correct to present things like Mr. President. Dress has just done it. Why Why ? Because we cannot budget the tendering procedures at this stage, for a reason that is intrinsic to the proposal we make. We will not put procedures into place until we have an opinion from the drug reimbursement commission on the molecules that may be affected, for a purpose you know well and which is the therapeutic protection of the patient to whom the products, in the end, will be delivered in terms of selection and quality maintenance. It is impossible today – unless we do divinatory art, which will ⁇ not be my case here – to establish budget projections. However, there are things that are certain today: the terms of exchange are very financial. This was recalled by Mr. Bultinck: in particular, the additional 23 million annually that the pharmaceutical industry put on the table, the approximately 40 million annually that the pharmaceutical industry, by lowering the age limits of old medicines, put on the table. These two measures alone represent 63 million.

There are, in any case, elements that we know. We know the share of generics in the drug budget (8% in volume, 6% in price); we know the share of non-patented drugs; we know the share of patented drugs. Therefore, one can have an idea of the impact of a full or reduced tender.

I would like to conclude with two elements of Mr. President’s speech. and Dresden.

1 of 1. The volume mass of generics compared to all medicines is 8%. The share in turnover is 4 or 5%. You say 6, Mr. Drèze, it doesn’t matter, it’s small. It is clear that in our country, the use of generics is far too low compared to other countries, especially in our neighbors. This is due to the fact that we have been delayed in this matter, especially during the previous legislature. There is a delay in the use of generics.

2 of 2. You say that it is not this bill that will solve all the problems of spending control and control of the overall healthcare economy. Of course no! We are in a global system. These are special measures, for a year, with other longer-term, more structural measures that are started here.

It is clear that we are in a global system. If we want to control the cost of health care in this country, the key thing is the empowerment of the actors both from the collective point of view – as we do today – and from the individual point of view. We have not succeeded in this and we will not succeed with special powers. This measure is entirely different: it is the accountability of the various actors of the system (doctors, healthcare institutions, mutual companies, etc.)

For us, socialists, this is essential, regardless of the financial and budgetary threats to the sector. This is the cornerstone of our action. It will be out of question, for us, to revise a system if it does not guarantee what exists today in the health care system, namely access to care, an important social system of protections and insurance, organized and controlled by public authorities and finally a medicine of the highest quality possible. It is in this spirit that we support the measures of the Minister.

Our health care system is good, let there be no doubt about it. On the one hand, it is good in terms of quality, accessibility, affordability and free choice, but on the other hand its limits have been reached. The accessibility, the cure and care are no longer what they have been. Patients pay more and more from their own pocket.

I have seen here some colleagues from the opposition swing with a press article. I ⁇ do not want to subdue for them. So I also found something, something very important: "The hospital bill has become 33% more expensive in six years."

The latter, “blue,” I do not understand.

It’s not about blue on the street probably. In any case, the limits have been reached. Therefore, Parliament should ⁇ not allow the growth of the budget by more than 4.5%, plus the inflation, which is already very high, to continue to increase, especially since we are confronting the aging, which is very quickly coming on our societies. We must also realize that healthcare spending is already growing four times faster than our economy is growing.

Unfortunately, we must note that the government lacks courage, that it lacks action, that there can be seen a growing immobilism, and that above all the aspect of survival is the only important guiding motive or link of the government. Unfortunately, the clock ticked relentlessly. People might be the victims of that.

It is also painfully illustrated by the way healthcare spending is increasingly dispersing. CD&V has abundantly warned of the approaching hurricane of the depreciating costs, which is becoming increasingly loud at the loops of the Belgian health. We have preached about this for a long time in the desert. After all, a couple of years ago, or a little less, the Crusade for life, for man and animal, proved to be more stringent. The youth should be educated decently. Sometimes, the minister entered the path of state powers. Fast food, hamburgers or other fatty food, that all had to be banned. No soft drinks or sweets machines at school. No tobacco sales, except, of course, in the backyard, on the bus circuit of Francorchamps. No alcohol advertising, no tattoos and piercings for adolescents. No sweets cigarettes. and so on.

CD&V warned the minister: the caring child of health care is becoming increasingly sick. However, the minister did not give home. At that time, he pursued animal rights organizations: no fur farming, no tail knot in farm horses, no circus apes, and so on. Therefore, no week passed or the minister came in the news with some kind of prohibition, all — I understand that, Mr. Minister — from a deep concern for the welfare of man and beast.

But CD&V warned again: in these times of great changes in society is not deciding very nefast. This could break our acid.

In the meantime, the clock ticks mercilessly.

The Minister of Public Health obeyes his vocation, makes people and animals healthy, if necessary against their will. He has done that well, but the time bomb of the departure of the health services continued. We were increasingly aware that there was a drastic change of course. Meanwhile, two important years have been lost. In his letter on the overall healing of fauna and flora, he is actually a very important element, the royal piece of power lost from sight, in particular: the healing of the health insurance. In the meantime, the clock continued.

Could the Minister not dare to address the excesses? Was there cold water fear? Was the minister afraid to encounter practical differences between the north and the south? Was the minister afraid that the findings could come to light that in the south of the country lives at a greater health rate than in the north? But the time bomb ticked, and in the meantime, the water reached over the lips. The Titanic is sinking, the orchestra plays the last note and panic becomes master.

Then the minister actually took to the last rescue bucket. He seized powers, which were taken out of the stale. The minister had the hands free to do almost everything he could to make the budget blow. If we pass the Health Act today — after two years of looking around, time-loss and thumbs, but above all debt build-up in health insurance — the federal minister of health is resorting to a superpower. The question is what he wants to do with it. Their

This is not a serious policy, but rather a game of panic football. How can we expect the people to take politics seriously when prutswork becomes the trademark?

The political moment was two years ago, when this government, after consultation with all relevant actors and following the agreements made regarding the financing and manageability of the health insurance, informed the healthcare providers in the field that the growth rate of 4.5% in the health insurance was insured. In the meantime, spending is rising to 10%, but up to that. That political moment is irrevocably wasted.

Now, at five o’clock on twelve, we have to wait for months for an announced bill. We expect a jewel, but we get climbing gold. The legistic work, as proposed in the committee, disrupts all imagination.

Colleague Goutry has, by the way, in abundance warned that the draft with the nineteen majority amendments would be unlikely to pass the examination of the State Council. We have then had to add to it a pattern list of amendments, improvement proposals, repair proposals, both substantially and formally. We have worked constructively until the nighttime and we have therefore made our contribution very clear. In the meantime, the majority has been degraded to a kind of compulsory courtesy.

Did or could they not explain their own amendments? I do not know. Speaker, be careful if the House is being degraded to a almost willy voting machine operated by a number of ministers and party chairs. We are not far from that. I would regret if here, as people’s representatives, we would become a grey army, a gang of ants to feed and protect the queen. That would be the last thing we want here. The Parliament must ⁇ not descend to the level of, say, the Russian Duma, where one actually has nothing to say.

The ministers consider the formal obstacle that must be taken, because the Constitution prescribes it in the making of a law, as a necessary evil. In order to obtain powers, one must pass through the Parliament. Wouldn’t it be more sensible to simply abolish the House of Representatives? This is how you can make your guest. Maybe another advice. If we would now also abolish the Council of State, you do not have to take this into account either. It does not happen, and thus it has become an unnecessary institution that is well critical when it comes to selling — I will return to that — too. That may not fit in the purple model state, so: go away with it.

Now I will briefly and concisely address the content of the Health Act, as I am supplementing the statement of colleague Goutry on behalf of our group.

A number of measures from the design are handled as a stick behind the door. Sometimes I wonder if the design is also a stick behind the door. Under the denominator responsibility, a number of issues have already been discussed and our spokesman has already extended this very extensively. There is the quality advisor, a superfunctionary who fulfils a bridge function within the healthcare sector with the coordination of all different data. For us, that function is superfluous, because today there is a network with existing structures that work well. It might be better to streamline those structures for information flow and so on, than to create new functions again.

We ask clearly: if that political choice continues – something we respect – it tries to give a clear signal to the population. The depolitization! In the framework of good governance, political appointments are definitely out of the wrong. I must point out that even the smallest public administrations, even the smallest municipality in the province, must fill open vacancies through comparative exams. The right man or woman is put in the right place. A fortiori, that should be true for an important top function, also considering what colleague Verherstraeten said here this morning: can all this pass the Copernicus test?

Regarding the care regions, colleagues, we hear in the walkways that the Flemish minister, in view of what Mrs. Vogels has done, should take a principle decision to establish or not establish Flemish care regions. There is no clarity about this yet. My question is how the other approach at the federal level, especially from programming, rimes with the approach at the Flemish level where one opts for cooperation.

Then, of course, there is the cherry on the cake: the Parliament is asked for permission.

Mr. Mayeur, now leaving, has minimized that cherry on the cake. I thought Mr. Mayeur would say that we would make framework laws here, but he did not name that. This might sound better. In any case, the truth is that through a KB all sorts of possible measures can be taken in case the budget of the health insurance is exceeded. In other words, the Minister requests a supercheck which is equally a blanco cheque. In that regard, referring to the time, when many more important powers were granted, is an inexpensive argument.

The State Council even said a few years ago that such a canary of a mandate can only be given in exceptional circumstances, and only if its necessity can be demonstrated by numbers. This year, unfortunately, we still have no figures that indicate a departure. Only a few contradictory messages were sent to the world. According to some reports, there is a large dispersion and according to others, there is no problem. Their

Maybe there is a lack of motivation. The principled objection, the use of powers, must be accountable. A criterion must be met. I gave in the committee an extensive consideration that I save you, about the interpretation of Professor Jan Velaers in his book "The Constitution and the Council of State". In it he says that for such a power deployment the state of emergency must be clearly present and must be clearly motivated. You can read this in the reports of the committee meetings.

In addition to the legal-principal obstacle, there is a substantive objection. So far, healthcare has been working with a number of subtle balances. Over the past two years, following the many consultation structures at the RIZIV, I have learned to appreciate the fine mechanics. With this authority goes this field, that work is overruled. I think that unilateral intervention will result in inaccurate, unproductive and sometimes linear measures. The Minister has already denied this. He has said that usually no linear measures will be taken, but that may come from it. That this work will be overruled will in any case work demotivating. I therefore fear that this will punish some good students and that transgressors will be rewarded.

This is also a panic reaction. Mr. Goutry has rightly said this. Twice he said that power is equal to powerlessness. I can completely beat it. It is indeed an emanation of the powerlessness of this government. Despite the continuously elevated growth rate from 1.5 percent to 2.5 percent to 4.5 percent plus index, we are still facing a large excess. In 2004 it was 513 million. We therefore believe only in a thorough accountability in which the individual healthcare provider, the individual hospitals, the individual patient are fully and accurately monitored and the expenditure profile is drawn up very accurately.

Per ⁇ that efficient technique was not used, because so likely some differences and transfers from north to south could become visible.

Now I come to the medicines. The market research, which we have just discussed, is being made possible, but only for non-patented medicines. We have said that Belgium is not New Zealand, that is clear. We need respect here, also for our own knowledge workers, for the pharmaceutical industry, a very important economic sector. In any case, the kiwi goes through with the new construction and is also folded.

Mrs. Detiège, for me, your chairman goes flat on the belly, after being the major advocate of the kiwi model for weeks. I would recommend him, before he makes all sorts of statements, to know his dossier. I think he saw everything as a kind of wary kiwi tape, a kind of melting tube, in which drugs outside and inside patents were joined together, while there are clearly large differences. If one sprayes many of those ideas, one must realize that they must be realized. Sometimes some high expectations must be fulfilled. If this does not happen, it is double painful. In this case, we must establish that the emperor does not wear clothes.

Unfortunately, I have been in the industry for fifteen years now. I always hear comments about Mr. Stevaert, that he cries and thinks and so on, but I note that he has managed to include important points in the health law in a very short term.

For example, we discussed substituting, prescribing substances by name and other measures in the pharmaceutical sector. When Stevaert then made a judgment, I was myself surprised that he managed to get it through. This is not said here. I find that really embarrassing.

There is a constant misconception. I will give a short quote on this. Together with Mrs. Avontroodt, you gave an interview in Knack, it is called "The Back". Do you know what she writes? She says to you, “You can’t deny that the kiwi model was originally proposed differently. Steve Stevaert, of the sp.a, and other politicians pretended to work for all medicines by tender. That was the ultimate image of the pharmaceutical industry.” This is about it. You have politically profited from what was coming. You communicate poorly with the public. You have created false expectations and now you have to return to your number. That is the painful reality.

I did not expect any other statements from Mr. Goutry. I regretted that he wasn’t here after that. The minister has been called a dry fig several times. I do not think that is a high level, but good.

Regarding the kiwimodel, I would like to say one thing, which has also been forgotten in the debate. The reference payment, for example, also exists in New Zealand. All this is forgotten. There is market research, there is the reference refund and there are a number of other systems.

There are also government pharmacies. In other words, the distribution is done in a completely different way. What is presented here is a very well-functioning form in Belgium.

The essence is elsewhere, Mrs. Detiège. Mr. Stevaert has constantly tried to tell the patients that they would be helped and that it had to be done with the pharmacy’s wholesalers. The money went to the people’s pockets. Well, everything will depend on the prescriber. If he continues to prescribe the most expensive, then the people pay the most. So the patient could even become the victim of your system.

I will soon finish the medicine section, but I will say two more words. More important than the welles-nietes game is that the patient ⁇ should not be the dupe of the story. I have the impression that the patient in this system has become very vulnerable and that he might sometimes turn up for the prescribed behavior of the doctor. For this, a key must be installed. I give that as a advice.

Mr. Speaker, colleagues, we are of course also of the opinion that the depleted budget of health insurance should be put on the rails again. We therefore share the concern that the policy should be aimed at making the best health care at an affordable price accessible to everyone. Why are blind authorities called for again? In the end, you had seen the mood hanging for two years or more, Mr. Minister. You were arranged by us notified. In the meantime, a lot of valuable resources have been lost in the health insurance. We were faced with a number of political decisions that were taken unconsciously, far from medical-driven action, in a budget-strict environment. I think, for example — I don’t endorse them all, but I give examples — the contraception checks, the free dental care and the in vitro fertilization, the so-called test tube babies. Those were popular measures, not only for couples who really need it, but for everyone.

Mr. Verhaegen, in order not to go back on this in the final discussion and save time just recently, I would like to say that if I can understand your annoyance over some anti-tobacco public health measures because of your sensitivity to the dimension of individual freedom, you will however agree that this is an important topic of society and that a Minister of Health who would not care about it would be a bad Minister of Health. Although your party has drafted a plan on this, I accept your criticism that measures against obesity are futile measures in public health and time is wasted on big balances. I want to understand it. by

On the other hand, I cannot accept your current statements, that is, we have lost money in measures to prevent young girls from getting pregnant. I cannot accept it. Keeping such words in this hall is serious.

I’ll just point out a few things to point out the choices that need to be made. Maybe the choices could have been different.

I will give another example: the maagrings. I can imagine that it is a problem for some people, but it is a political choice: you can work preventively around, for example, exercise and diets, but you can also pay for the expensive procedure. However, if you take the money out of the RIZIV greenhouse, there are other things that can no longer be paid. This may be at the expense of cancer patients.

The prevention policy.

I just want to say that it is important to use the resources properly. This is necessary because the resources are scarce. We must find out that there is a gap in health insurance, despite the fact — we must dare to face it — that the share of the patient increases more than the RIZIV budget. Therefore, there is a shift of the invoice towards the patient. Hospital costs for the patient have increased by 33% in 5 years. The patient already pays more than a quarter of all health expenditure himself through brake payments or through — it may already be the beginning of a sluggish privatization — supplementary insurance. It also causes pain in the wallet.

The time of easy solutions to difficult problems is finally over. If we want to keep the social security system standing, we need to key to the system, which is standing. It is already a pivotal piece to keep healthcare within that 4.5% growth standard. However, according to the OECD, the growth rate can reach a maximum of 2.8% between 2008 and 2030, as the hurricane of aging approaches and the loops of our welfare state crumble. The OECD also urges Belgium to take structural interventions to keep spending under control.

So it is time for courageous, fundamental choices. We must have the courage to debate openly about the boundaries of publicly funded health care, about the distinction between the necessary health costs paid by the health insurance and a number of "comfort costs", which have been alluded to several times in the committee. It is therefore an important aspect, because the greener Belgium becomes, the stricter the health insurance will be in the greenhouse and the sharper the demand for sanctions will sound. Who will punish you first? The blind, the chain smoker, or the obese? One must put the tering to the nering: it is not a "and-story", but a "of-story". The debate on the choices will have to be held.

First and foremost, there is a need for a efficient budgetary process that can quickly and efficiently detect spending and depreciation. It has clearly shown that the healthcare budget needs to be permanently controlled, not only by the Minister of Health and the government, but by the entire Parliament.

Furthermore, we also fear that this saving effect does little to change the structural disadvantages in the Belgian system. To this end, I would like to propose two, for me important, structural solutions.

First, the structural intervention in a public apparatus also implies that a greater responsibility is placed on the provinces and that the communitarianization is fully implemented. I actually refer here also to the five resolutions in the Flemish Parliament, which were adopted in 1999 and which, by the way, were also confirmed in the Flemish Government Agreement last year. I quote the third point: "A transfer of the health sector and family policy to the Communities". This is also considered important by the Flemish government. We do this not to regionalize, but simply to have a consistent policy with homogeneous power packages.

The transfer of full health care to the Communities is necessary for us, starting with the care of the elderly. Colleague Goutry once said that three-quarters of the elderly care policy today already belongs to the Communities, while one of the key components, in particular the financing — for example from the resthouse sector — has still remained federal. Furthermore, to give that example now, for our care of the elderly, more than culture or education, it is a matter of personality. I think there is something to find for that.

Today, there is also a huge fragmentation of powers between the federal level and that of the Communities in healthcare. These fragmentations show no logic. I searched for them, but they came into being artificially as a result of probably phased and incomplete state reforms. This also makes the management of the various sectors very complex and complicated.

Proposals for the regionalization of healthcare are also far from new. I remember in the 1990s having attended a number of days of study in connection with the split of healthcare and health insurance, but the arguments that were then given pro split were financial. Today it is more about the substantive argumentation. Today we stand with our nose on the facts. The Flemish vision of health care policy is completely different from that of the French speakers. That may. I have respect for the two communities. Healthcare is a personal affair. I have already cited that. There is also inevitably a correlation between preventive and curative health care. It is therefore obvious that those who conduct a good preventive policy must also be able to reap the fruits of it by, for example, reducing costs in curative care. That is what I mean with those homogeneous powers. Everyone is also aware of the great differences in medical culture and policy preferences between Flanders and Wallonia. There will always be differences in care culture and organization. There are even various accents observed in medical education. The settlement of the quota was also discussed last year. There are also different accents, even in terms of illness absence. We respect the fact that people in a given region want to be sick longer, but then you must also bear the consequences.

Finally, I refer to the correct application of the principle of subsidiarity, which has also been confirmed at the European level. Decision-making should be at the lowest possible level where there is still an acceptable quality guarantee.

Colleagues, the demands that the VAZO, the Flemish General Hospital Consultation, put forward at the end of last year, ⁇ did not come out of nothing. They survived and were carried.

Mr. Minister, I can also not get rid of the impression that you continue to oppose important structural reforms with the greatest affection, but also with the equal tenacity, which could immediately address a number of unfair transfers. Their

Again and again, our motions were rejected with some radicality by the majority and simply passed to the agenda. These motions, however, cautiously asked the government to report to Parliament, for example, on how the differences in healthcare consumption between the north and the south are corrected or on the measures needed to bring everyone to their responsibility and to effectively implement those measures. Thus, the draconian questions were not the ones we asked. Their

The current plethora of governments responsible for health care is also inefficient. For abroad, it is ridiculous that nine ministerial agencies in Belgium are dealing with health policy. That’s almost an entire football team, while one per Community would definitely be enough.

The [...]

Mrs. De Block, these are the facts. Their

The community level is indeed, in our opinion, the most efficient level for the whole health policy due to the mentioned differences in emphasis between the two Communities, which we of course respect. Their

Now we must establish that there is a federal recovery. I will not repeat everything, but give two examples, namely the healthcare regions and nuclear medicine, with a regional recognition and where the law is therefore interpreted differently. I also think of some illegal scanners, and so on. A second important proposal is that our party opts for the standardized electronic patient file. Colleagues, good savings in health insurance are often situated not in large spectacular measures such as the kiwi model, but also in less striking measures, with changes to the system, for example. Their

Therefore, we advocate a kind of standardized electronic file per patient. Every healthcare provider should be able to consult the same secure customer file, with all the data, including which tests to undergo, but also what allergies the patient has and what medications he needs. As a result, the healthcare provider immediately receives an overview and also pays much more attention to the patient’s overall care path. This is, in our view, the means of improving the quality of care and also the means of improving the safety of the patient and of controlling the expenses of medical care. Their

I think such a central information system for all hospitals is very important because it could exclude, for example, double examination and also address excessive prescription behavior. Such information systems should be given priority. The central government, for the time being the federal government, could then conduct a kind of flankering policy here. It then receives, for example, the data from the hospitals, ensures that, for example, the computer technology is supplied and that it is compatible, that the medical numbers are secured and so on. Everyone should be able to communicate with everyone. This is also a finding from the OECD and last year’s McKenzie study, which stated that such a vision with the associated investments is of priority. I am therefore pleased, Mr. Minister, that in your answer to the question of Mr. Vandeurzen, you have answered that this electronic health dossier is indeed being worked out. I hope that in informatization a breakthrough can be realized because otherwise this is another missed opportunity.

Ladies and gentlemen, I am going around. Medicines, doctors, elderly care and the maximum invoice appear to be the main causes of the shortage. The CD&V therefore asks the Minister to inform the Parliament on a regular basis of the budgetary measures taken and their impact.

Finally, I have another observation. I then wondered what it makes sense to carry out a budget control next week while there is still no view of this year’s health insurance figures. To make the story even more complicated, there is the social agreement that the federal government has concluded with the trade unions for the health sector, without involving the employers. Understand who can understand. I have been told that for this agreement 55 million euros must still be sought within the RIZIV budget. This will ⁇ not be a sinecure with a deficit of 513 million euros for 2004. To conclude an agreement without having certainty about the funding is careless unless one is going to spread the hot potatoes to the facilities. We hope that this will not be the case. This sometimes reminds me of the story of the village and the law street who go to drink a glass together. When the waitress comes with the bill, the law street has suddenly disappeared. You cannot do that, Mr. Minister. After 6 years, people can still smell the smell of baked air.

Mr. Minister, while asking for a mandate and indicating that the health insurance is in an emergency situation because the deficit has never been so high — according to objective sources more than 500 million euros in 2004 — your party chairman stated that there is no problem and that the deficit should not be overlooked. Why is the sky suddenly clear? For me, that is a mystery. Your party chairman has said that those who raise the problem have other intentions, for example, the privatization of health insurance.

To say it in the language of Molière: tout va bien; il n'y a pas de problèmes. So why do you need that superpower, Mr. Minister? I would like to ask you this relevant question.

The last two speakers in the general discussion are Mr Drèze and Mrs Avontroodt.

After the Minister’s response there will be the discussion of articles and amendments and probably we will be able to proceed to the vote shortly after 18:00.

I have two priorities, if you allow it. The first one is mainly for your attention. I would like to thank very warmly the services of the Chamber for their services in the week before the Easter holidays, given the pace of parliamentary work and the permanent presence of some staff members on the day of 22 March, the night of 22 to 23 and the day of 23 March. Some people in this house remained largely more than 24 hours at their workplace, which, by the way, is in flagrant contradiction with our labor legislation. Hopefully this will not happen again, or at least not too often.

Mr. Drèze, there was a time when we had on average one night session per week. I must say that with the courage and ardor of the staff you report, he survived, as well as the members of the rest.

If you allow me, this does not justify everything.

( ... ...

It must be said that you contribute appropriately to the reduction of the working time of our assembly, Mr. De Crem.

I would like to especially welcome the quality of the report which was made in 24 hours, which includes the fact of grasping the scope of our exchanges, summarizing them and sometimes even improving them technically, translating them, printing them, etc. I must say that being relatively recent in this house, I am quite amazed by the quality of this work. The second prerequisite — I know it has already been done at other times but I will recall it in the plenary session today — is to regret the conditions of this parliamentary work before Easter. Mr. Minister, there is indeed urgency in this matter, the CDH has never challenged it, but we do not accept that, for a certain time, the government and the majority are dragging and then suddenly things are hastened, in particular by large amendments deposited by the majority parliamentarians in the afternoon of March 22, or even in the night. Hence, in some respects, an insufficient quality of the texts, which justified our request to postpone the vote in plenary session to this week. I think the work in the committee yesterday showed that this postponement was useful.

That being said, I will make a short general speech in three points, then I will present the reason for the submission to the plenary session of a part of our amendments by taking them one after another.

I will not be surprised to start with a budget discussion. I do not do this to upset you, reassure yourself and not after the exit of the President of the MR, Mr. Bacquelaine and Mr. Michel — I will return to it — but simply as every time, at the beginning of our work in commission: I contend to lead blindly a work of such a scale, I say it simply but firmly.

The recovery of the health care budget is the goal of this law. Currently, we do not have a board board. The only structured note, notable in some respects, is that which you have deposited and approved by the Council of Ministers of 26 November 2004: a document of 38 pages, based at the time in urgency on the technical accounts of the INAMI, concluded on 31 August 2004.

We find in your pen, Mr. Minister, a precise assessment of the budget surplus divided by sector, a structured catalogue of several dozen proposed measures with an expected budget performance measure by measure. We agreed in the committee that these amounts were indeed estimates but it does not preclude that the effort of precision was well present.

In the field of medicines, a sector which is ⁇ concerned with us today, majority as opposition, eight pages of this document reiterate, point by point, a series of findings and measures with expected yields. Understand my wonder that today, five months later, with a bill, far more refined in terms of measures taken than this note of 26 November 2004, we no longer have any budget projections.

The INAMI communicated, on Monday, April 11, 2005, the technical accounts on December 31, 2004, namely after the bill was voted in committee before Easter. These latest figures demonstrate, in our opinion, that this bill, adopted today, no longer or not sufficiently matches the budget objective.

You are an educational economist. You have been a Minister of Economics. You know, of course, the importance of board boards. We do not understand why you were able to submit a structured note on 26 November 2005 and that it is no longer possible today, five months later.

I now come to the exit of the French-speaking liberals for about 24 or 48 hours. We do not understand their departure. Mr. Bacquelaine, I heard you long on RTBF radio this morning, the CDH does not accept this way of expressing itself. Whether you estimate, in particular, given the excess of the budget each year, that it is not normal that the INAMI produces data so late and without sufficient reliability, or, we all think it and we said it when the minister met us in emergency in November, following the deficit of 634 million announced by the INAMI, just a few weeks after the adoption of a 2005 budget planning on a budgetary balance for 2004. We were all behind you, Mr. Minister, when you announced an audit request in order to see it clearer. If your liberal partner thinks things aren’t moving fast enough, let them tell you in the government behind closed doors. What we do not accept is to weaken you, or even humiliate you publicly and free of charge.

The ⁇ severe circumstances for the survival of our health care system require, whatever it is, a strong, sustained and long-term functioning Minister of Social Affairs. Better than anyone, Mr. Minister, you know that your wallet is heavy, complex and at the crossroads. Better than anyone, you know that the healthcare sector needs well-focused and large-scale structural reforms.

The CDH accepts, especially if the MR does not give you the lesson while it is the same party that has compelled you to review your copy in the field of medicines. I will return to this in my amendments at the end of this speech. We affirm it: unless a miracle happens, the current text will not allow the budget objective to be achieved. You will then be obliged to resort to special powers, forgive limited authorization powers, because you are right, these special powers are limited by the fact that they must be approved in the Council of Ministers. So you are already under the control of the government.

To add a layer, today, Mr. Bacquelaine, with the idea of a permanent monitoring before even knowing the effective impact of the health law, it is either to recognize that this law is insufficient, or to discount your Minister of Social Affairs free of charge. This is a dangerous game, because weakening a minister in office means, in this sector, giving more credit to two alternatives that humanists and socialists reject: communitarianization, on the one hand, and privatization, on the other.

I don’t think the MR wants communitarianization of health care, but I would like it to be clear. Is it in favor of even partial privatization of healthcare in Belgium? Does the MR support this vision recently expressed by the ABSyM (syndicate of doctors)? Mr. Bacquelaine, you are a doctor. Are you on the same wavelengths as your medical colleagues or socialist colleagues?

My third point of general intervention concerns employment. I had sent to the Minister, at the end of January, a detailed note on the position of our party when it came to negotiate, with the unions of the non-market, an agreement for the coming years. The government has decided to provide 10,700 additional jobs spread over six years, which we consider quite insufficient to meet the ever-growing needs of health care. If I’m talking about employment now, while it’s not listed explicitly anywhere in the bill, it’s that developing employment in the healthcare sector is, of course, a decision that has a budget impact.

The government’s decision to provide 10,700 jobs corresponds to 4% of the increase in existing employment, while over the last four years this growth has been 16%. Therefore, it will be four times smaller for a 50% longer period of time.

We estimate that the growth rate of 4.5% per year of the healthcare budget should apply sector by sector. Also, we do not understand that, for medicines, we give 13% increase in 2005 and that for employment, we simply stay with the growth of wages, which is expected to be 2.15% per year. We also advocate for employment in this “subsector”, and for a growth of 4.5%, which would leave a budget margin of 2%.

Mr. Speaker, if I understand the humanist on the tribune, he considers that a certain number of medicines must be removed or, in any case, the prescription of them to the sick who need them must be prohibited. That’s how I interpret your words, Mr. Dresden.

Therefore, you did not listen to me in the committee yesterday when we submitted our amendments. I will return to it later.

You say you need to go down from 13% to 4,5% for medicines. I want it to be better, but what does it actually mean?

This means, not to remove medicines in the treatment of certain pathologies, but to limit inadequate consumption both in volume and in price. Hence all the discussion that we have had recently, and to which I will return, regarding the tender for patented medicines. It is unacceptable for us to make greater efforts for generic drugs and non-patent drugs than for patented drugs. It would completely destabilize the pharmaceutical sector in Belgium than to proceed in this way, at two speeds.

I return to employment. By granting 13% increase in 2005 to the drug sector, the government, I recall and I confirm, mortgages its capabilities to create necessary jobs in healthcare institutions.

And 26,000 jobs in the pharmaceutical industry, I noticed. The CDH considers that the pharmaceutical industry must leave this country.

I never said that!

Yes, you have said this several times in the commission. We must accept what is said!

Mr. Bacquelaine, you are lying! We will read the report together. We are in plenary session.

... of parliament, since you said just recently that the fact that you sometimes work at night seemed completely supernatural to you. Your words seem uncivilized.

I have this and commission...

I leave you judge by your way of seeing things, I am not ⁇ surprised.

I said in the committee that it was necessary to look at the 26,000 jobs you are talking about and which are real between research, on the one hand, and production, on the other...

I take note that the CDH is for the breakdown of the pharmaceutical industry in Belgium, each to assume its responsibilities in this regard.

You take note of what you want, but these words, I never kept them.

I return to the amendments that we hold in the plenary session, starting with heavy equipment. First, in terms of magnetic resonance, we take note and we share your view, Mr. Minister, that a tight programming is no longer required today. The fact that there are about fifty authorized devices and a hundred devices actually operating somewhere across the country is to be considered. by

In the case of PET-scan, we maintain the two amendments defended in the committee. Indeed, as you yourself acknowledge, Mr. Minister, the exceeding of the norm is observed in the three regions of the country but, in the face of this, our proposal is more nuanced. Unlike magnetic resonance, we agree with you that PET-scan programming can still prove useful. A hospital cannot invest in a PETscan merely for a matter of brand image, without that choice based on patient and medical benefits related to the investment. We all have one or the other recent breakthrough on this subject.

However, the standard of thirteen devices for the country is currently insufficient.

I said “recent.” I will not mention a region. You know very well what area I mean. It is not mine, it is not ours.

We know that today there are about twenty-two devices in operation, sometimes two or three in the same institution, and this both in the north and south of the country. by

I refer to the report of our work, page 84, where there are some elements that I mentioned and which are taken up in an opinion of the National Council of Hospital Institutions (CNEH), opinion which I find most interesting. I recall the successive opinions of the CNEH of 13 April 2000, recommending 19 PET-scans, of 10 July 2002, recommending 20 PET-scans, and the political decision to limit the number of PET-scans to 13. The CNEH’s draft opinion of 13 May 2004 refers to 30,000 PET examinations per year, i.e. 1,600 examinations per device. by

Given the examinations carried out in 2002, at the number of 16,894, the medical necessity that waiting lists do not exceed two weeks, the fact that the maximum extrapolation could reach 20,000 examinations per year - while the demand on medical basis is in the order of 30,000 -, the fact that the geographical distribution of the number of PET-scans is not considered optimal and various other elements highlighted in the aforementioned opinion of 13 May 2004, we consider concernful the provisions of the draft law regarding PETscan.

The Minister said he would wait for the requested opinion from the Federal Centre of Expertise by the end of the second quarter of this year to eventually review the programming in the field of PET-scan.

I maintain my two amendments because the CDH is already of the opinion, on the basis of the data currently in our possession, that the 13 standard is currently insufficient. The two amendments we propose provide guidance on how to implement a reform with the increasing number of devices.

I will read our amendment number 50 because it is important to us. We would like to add in the text the following words: "Taking into account a geographical distribution adapted to pathologies, the King determines the conditions under which it may be derogated from the above criteria for the institutions members of an association of hospitals having an intranet computer system guaranteeing the justification and transparency of the examinations prescribed and carried out. The King shall regulate the modalities for the control of the above-mentioned examinations.” I think we have here a concrete example of a care pool where a series of hospitals joining together in an objective way to share a heavy apparatus could more justify the acquisition of an additional apparatus than by an isolated institution.

Another way to group in a relevant way is therefore to have an intranet that helps to avoid unnecessary examinations. This is, above all, the objective to be met. A PET-scan examination is still invasive for the patient and it would obviously be inappropriate to practice it unnecessarily. An intranet system would allow to a large extent to control possible drifts.

The second amendment would aim to add to Article 64, former numeration, 1 er § the following sentence: "that paragraph 1 er in question does not apply to devices and services installed or operated before the entry into force of the Royal Decree of 12 August 2000 fixing the rules relating to the maximum number of nuclear medicine services where a PET scanner is installed. Indeed, one or the other device was installed in our country in 1998 or 1999 - what we call "in tempore non suspecto" - before the entry into force of the federal programming. It would seem to us that in the event of an increase in the standard beyond 13, these devices should be legalized as a priority.

The second type of amendment at the level of care basins. We have said it from the beginning, this is not new to you, Mr. Minister, we are for care basins, but with two preliminary. The idea of care basins is only realistic and desirable if public structures are upgraded compared to private structures and are therefore, in advance, made autonomous and responsible in terms of their financing. Furthermore, and as a second prerequisite, the dynamics of the care basins must also start from the actors themselves, in full freedom, in a climate of trust. We do not dispute that, if in some regions, we are behind compared to others in the implementation of care pools, an impulse must come from the public authority, but we would not accept that this public impulse translates into arbitrary, authoritarian and non-negotiated programming.

We have submitted a second amendment regarding care pools which aims to maintain in the health law an existing sentence, ensuring that the reference to equity in the distribution of resources between the different networks is respected, in any case until the end of the implementation of your care pools project, otherwise there is a risk of a breach of trust in the head of the different networks active in the healthcare environment.

I now come to the emergency services and the flat-rate contribution that currently amounts to 12 euros, but which would be reduced in the health bill to 9,5 euros, or even to half that amount. We find that in some regions, hospitals have decided not to apply this flat-rate contribution and therefore to deprive themselves of a budgetary prescription. If these hospitals have decided to do so, it is mainly because they consider that asking for small amounts of this type to emergency patients is a hassle ultimately more expensive than the prescription that this flat-rate contribution can give them, and that it is not the most suitable tool for solving the problems faced by emergency services.

Even though he is absent, I would like to remind you that Mr. Mayeur supported our amendment in the committee. I would also like to point out that Mr. Mayeur is co-author of a bill on the agenda of our work. I regret that mr. Mayeur agrees to see his proposal "absorbed" by your bill. Indeed, in this matter, the provision held by the government, even if it pursues a praiseable and justified goal, may not be the most appropriate way of achieving it.

Then comes an amendment on children with cancer. I talked about it in a committee for a simple reason: a few weeks ago, in this room, by absolute unanimousness, parliamentarians adopted a resolution aimed at supporting by liaison teams the care of children with cancer staying at home. In addition, another proposal for a resolution to cover the costs inherent in the treatment of a child with a serious disease was submitted in October 2003 by MM. Bacquelaine and Ducarme. It is good to make resolutions, but it is more useful to be operational. That is why we have included an amendment on this subject in the bill. You answered us in the commission that you had progressed by another way. That’s the case, and it’s a good thing, but we think our amendment can be accepted as well.

With regard to special powers, the CDH confirms its opposition to special powers for four reasons.

The first, ⁇ the most important, is that we have a tradition in Belgium, in the field of health care as in the field of employment, to respect a number of essential principles such as the consultation between service providers, insurers and the authority, the traditional mechanisms of budgetary control, deadlines, etc. Moving beyond these constituent principles would inevitably trigger counterproductive raids by health care actors. We think it’s better to take the time to coordinate, even if it takes a little longer and it’s a little harder, and to associate them with decisions, rather than wanting to go faster, to rush things but to have the actors against themselves in the execution of which they are charged.

The second is that any measures dictated by budgetary control in the current fiscal year can be implemented sufficiently quickly, in compliance with the procedures and timelines provided for by the current regulation; Vandenbroucke made it in 2002. Moreover, we know, especially in the field that we are concerned with today, that the government sometimes takes more time to conduct arbitration within itself than the parliament to examine what is submitted to it by the government.

The third is the 2004 budget deflation that we have seen and which is, let me simply say, the result of a policy lacking sufficient structural measures of budget control in recent years. Such structural measures must ⁇ be taken today. However, they must be thought out and comply with the essential rules of consultation in force. Parliament and health care actors cannot be held away from such an exercise, even temporarily.

The fourth reason relates to medicines. As the CDH said in a press release, it agrees with the objective but it finds that structural reforms, allow me the game of words, go "to the blue" and that healthcare remains in the red. by

The CDH supports the objective of budgetary control underlying the bill. The final figures are now known for 2004. 513 million euros is the amount of the health care deficit. Certainly, this amount is lower than the first first figure estimated at 634 million euros; this is good news but it remains true that 513 million euros is a colossal figure. by

A sector-by-sector analysis shows that, once again, it is the pharmaceutical sector that eats the largest portion of the surpass with 372 million euros. When I say “again,” I refer to a February 2005 study of Christian mutualities that looked at the evolution of the health care budget over the last ten years and found, on average, an increase of 5.8% per year of the health care budget and, at the same time, at the level of medicines, an evolution of 7.5% per year. by

Over the past ten years, there has been an additional 2% increase in the field of medicines compared to the general healthcare budget.

Today, the drug accounts for 72% of the budget surplus of 372 million euros for 2004. This percentage is rising compared to previous years, while the pharmaceutical sector accounts for only 19% of healthcare spending. by

Excesses are also seen in other subsectors: medical fees of approximately 50 million, the maximum to be charged of approximately 50 million, rest and care homes of approximately 50 million. In other subsectors, sometimes a bonus is recorded, sometimes a mali that balances globally. by

So we all know today the four sectors where efforts need to be made. by

If the pharmaceutical sector represents the largest part of the budget surpass, it is precisely in this sector that the health bill has been eased at the request of the liberals who, I recall, still today demand a monitoring of the budget.

Patented medicines have been removed from the bidding system, which significantly reduces the expected budget objective. This withdrawal is supposed to have been offset by the imposition of a new tax on the turnover of the pharmaceutical industry. But this new tax is expected to bring only 23 million euros, a sum to be put into perspective with the budget surpass of a total of 371 million euros. by

The CDH regrets this reversal because it does not constitute a structural policy of spending control. As an alternative, we present today two amendments that are linked. by

The first was submitted to the committee yesterday. It aims to reintroduce patented drugs into the bidding system but in a more nuanced way than in the government’s initial project. We are sincerely convinced that this amendment can respond to the concerns of some while respecting the budgetary objective. It also helps to maintain the quality of care.

The second amendment was submitted before Easter. It aims to make additional efforts at the level of generic medicines. In fact, the refund rate should be increased from — 26 to — 30%. If our first amendment on the tender is voted, an additional effort on generics can be made by raising the refund rate not from — 26 to — 30% but to — 40%.

That being said, if our first amendment is rejected sooner, we will remove the second amendment because we do not want to aggravate the now established imbalance between the different subsectors of the drug, namely, the sub-patent, the non-patent and the generic.

Mr. Minister, if, under the pressure of the industry and the liberals, you confirm your retreat in this matter, you will need – we are unfortunately convinced of this – special powers. When you present yourself before the Council of Ministers with proposals on the subject, you will again be confronted with your liberal partner. We wish you good courage! by

Finally, even if we are opposed to special powers, we will listen to you when you come to explain, as you have committed, before our assembly. We will then see if we can support you in this matter not by a vote but by other political means.

Thank you, Mr Drèze. The last will be the first. Mrs Avontroodt, you are the last speaker. Then the Minister follows and we will discuss the articles and amendments. Their

Mr. Drèze, I thank you very much for addressing the amendments in your presentation; this will facilitate the work of the President so far.

Mr. Speaker, Mr. Minister, colleagues, first of all, I would like to say that there is indeed a consensus in the committee: the patient cannot become the dupe of this law. Mr. Goutry, before you react, I wish I had completed my explanation first.

I would ⁇ also address colleague Drèze who actually expressed that threat. However, I am convinced that this will not be the case.

I would like to start with a quote from Willem Elsschot and apply that to the minister. Mrs. Detiège knows the quote undoubtedly, because when entering Antwerp along the left bank you can read on the Chicago Building: "Between dream and action are often laws and rules and many practical objections".

The dream of every health minister in Europe is the reconciliation of quality with the manageability and affordability of care. That is also your dream, Mr. Minister, and until today you realize the 9% of GDP, which is also the average of the Western European countries.

Then we come to the act. Why has it so far not managed to control spending? Neither the Minister’s predecessor nor his predecessors have succeeded in implementing a policy that focuses on health targets rather than budgetary targets. Their

Today we still bear the consequences of the lack of coherence. There have already been several ministers of Social Affairs, including with the CD&V in the government. But there was only a programming policy, a policy-focused offer. Maybe it was according to the spirit of the time, but the offer was created. The fact that healthcare regions need to be created now and that efficiency and rational policies need to be sought now has its roots in recent years.

Mr. Verhaegen is not there. I’m not talking about guilt, Mr. Goutry, I just want to say that you too often blow warm and cold at the same time. On the one hand, you say that there is absolutely something to be done. I hear you systematically and consistently say that something needs to be done urgently. On the other hand, I hear you — often rightly — accusing the underfinancing and advocating for more funds for, for example, mental health care or home care.

I also hear you advocate for more resources for home care and with regard to underfinancing. You have stood on the barricades regarding the structural underfinancing of hospitals, with arguments, with your knowledge on the subject. Well, this law encompasses precisely a number of structural measures that I have not seen in my even shorter career than yours in this house.

Mrs Avontroodt, that is an invitation to Mr Goutry to intervene. Mr. Goutry, very briefly then.

Mrs. Avontroodt, you know that I appreciate that you always try to conduct intellectually honest discussions.

First and foremost, we used to work for eight years with a growth rate of 1.5% instead of 4%, while the average annual spending over a 10-year period was on average around 4% or 4.5%, real growth. We are now at 9%. This is a huge difference in spending.

Secondly, 25% of the budget is not spent efficiently. This is about it. It is not always about more money. We don’t always ask for more money. We demand the use of the resources in the most efficient way. If it turns out, Madame, that there is too much money going to technical performance because of unnecessary surveys and double surveys, sometimes because of melting money and machines, and so on, then that money should indeed flow to the mental health care where there is a shortage. It is not always a story of more. It is a story of efficiency. Minister Vandenbroucke had initiated the responsibilization; Nagaan, piece by piece, what is spent, for whom, at what cost and these elements compare with each other. Then we are well and we are conducting a good policy.

Why not do it instead of giving powers? Giving powers is capping. That means cutting off the top; that means cutting off the excess that arises somewhere. It does not solve anything structurally. One solves something structurally only if one knows the causes of the excess and if one eradicates them with root and everything. Then they do something.

I have no problem with what Mr. Goutry says. The pursuit of efficiency and rational policy is evident. No one in this hemisphere, I think, has any objection to it, on the contrary. You are not the first to say that, Mr. Goutry. I think this has already been said in all banks. This is absolutely not new.

However, what you just said, knowing that at that time, in your time, the budget increased by 1.5%, that will be correct. This may have been the same with the other countries. How much do you think the budget is now increasing in the countries around us? How much do you think? Is it still 1.5 percent? I do not think. So, intellectual honesty should play on both sides. The budget is now increasing. You know the causes because you have brought them up so many times, precisely because it is the reality. That there should be a scientific analysis of the cost-increasing factors is completely correct. In order to do so, one needs to have exactly the correct, recognized, aggregated data.

I will return to my argument, Mr. Minister. As I said in the committee, I feel there are only two serious gaps in that law. First, there should be even greater efficiency and transparency in data management. That is a debate that we held in the previous legislature when an embryo emerged of a way to make that data transparent. Certain forces in this country still provide transparent data to the minister, which should be able to carry out the policy with it.

The second hole, and also that is not new, is the whole hole around ehealth and the electronic medical file as well as Telecare. This gap is also missing, but I understand that it has already been a lot of work to complete this whole. If we want to be able to continue equalizing or preserve our excellence, which we have in the home, then there will have to be invested in that area first before it runs.

A lot has been said about the pharmaceutical industry. We have tried to polarize and dualize. Our group is not embarrassed to say that we fully support what is in the law. After all, we believe that this will be a win-win situation for the patient in the first place. The patient now has no risk of not having access to innovative medicines, to have to resort to abroad to get new and innovative medicines available there and last but not least we are... Collega Drèze cannot listen now, but I have waited until I stood here to support my colleague Bacquelaine in this. Collega Drèze has made it very clear in the committee that employment does not all offer so much. I must honestly say that I found this a rather shocking statement for someone who comes from a region where huge research and development is taking place. I heard yesterday on the radio that new places are being created in the vicinity of Charleroi because Johnson & Johnson is investing there again. 135 jobs will be added to the research. I think this will be a positive result of this law.

I will leave it for the medicines. All facets are included. Procurement for non-patent drugs can be for us because our party very clearly says that patent and research should be protected. This is the basis for new developments and innovation. It is an intellectual property right. This is one of our greatest assets in our country that allows us to position ourselves in a global market where globalization is no longer a loose word. All this is linked to only one principle: everything based on therapeutic added value. Therefore, I am very pleased that the amendment, which we have supported with the members of the majority, refers to equal indications but also equal mechanisms of action.

It is essential that patients treated for a particular condition are entitled to the best therapy and are not treated with two rates.

Mr. Minister, on how that should be implemented, there is ⁇ consensus to effectively defy and ban the real me-too. They are probably one of the biggest cost-inducing factors.

The CTG is being professionalized. You have laid the basis for this. This is also necessary and necessary. The investment in the independence and professionalization of the CTG, which must be more based on health, economic and pharmaco-economic methods and which must show the greatest transparency, will only benefit both innovation and cost management.

Now I want to talk about the powers.

Which member of parliament is now happy with powers? No one . Mr. Minister, there are colleagues who, with their glass ball, present a doomscenario and say that nothing can come out of it, that it is impossible, because the powers are an empty box. I have heard other arguments here too. Well, I’m not a hypocrite and I don’t have a glass ball. Nevertheless, through what I hear and read in the medical and in the public, general press, I know that there is a shift in thinking. One becomes aware that the proportional increase in this way is unsustainable. At the base, in the education and in the training of all healthcare providers, automatically more attention will be paid to the problem.

There are indeed syndicates against the proposals — I see Mrs. Detiège already smiling — but that is the role of syndicates. The workers’ unions are fighting for better wages and better wage conditions. The medical unions are fighting for the preservation of their honoraries. Hospitals are not syndicates. They stand for the viability of their sector. Is that abnormal? It is obvious. That is also their role. For this reason, however, all actors should cooperate with the Minister. Maybe and ⁇ the stick behind the door was needed. We have full confidence that it will succeed. We did not get a consensus conference, although I have repeatedly pledged for it. We did not get them, after the Health Dialogue. I regret it and continue to regret it. Who knows, it would not have been necessary. However, I do not have a glass ball.

Let me go back to the maximum invoice. The fact that those expenses are rising is something that was sung and called by our colleague Jef Valkeniers in the previous legislature in each committee: be careful with the maximum invoice, because that will rise, that will not be 4 billion, that will be much more. He was right, we see it here. In my opinion, Mr. Minister, you should still introduce a number of corrections regarding the maximum invoice. These corrections are not intended to eliminate the maximum invoice. Safety and affordability for the weakest and most vulnerable in society must be ⁇ ined in every way. In my opinion, there are two ways in which we can improve the maximum invoice. Their

The first clue — to investigate, because I do not have the truth in custody — is for sure to make a medical maximum bill of it. Why do I say that? Because for a number of chronic diseases there are also forfaits. That flat-rate payment for a number of chronic diseases actually hits twice in the maximum invoice. In fact, I think, Mr. Minister, that you should have this priority examined and the double financing of both forfaits and maximum invoice analyzed. There is a second track. We have prepared a bill for that, which may be on the agenda, but our president is not there now. This is the double payment of the maximum invoice and the additional insurance. I’m not saying this is the biggest cost-driven factor, but in percentage it has ⁇ been a huge increase last year, in 2004. Per ⁇ this trend will not reverse if we do not take action there too. Their

Now the nomenclature. Colleague Maggie De Block has interfered in this, and rightly. Indeed, there are several bodies competent to evaluate, amend, adjust and update the nomenclature. There is the centre of knowledge, there is the technical council, there is for a part the National Council, there are the colleges for doctors: all these bodies have in their mission that they should update the nomenclature, that they should draw up the nomenclature, or that they have their say around the nomenclature. This committee is ultimately a form of monitoring. I see this as a permanent monitoring. The Technical-Medical Board has the necessary expertise in its field. I have no problem with the fact that this is actually being done. You had your visit to France. There are still examples in this regard. I really think this is a good supplement and I am not shy of saying so.

However, it is true that if we create a committee, one or two should be abolished at the same time. That is so. Doctors and healthcare providers must be rational in their behavior. The government and the government should do the same. A good manager should also fill these points qualitatively.

As for the recommendations, I refer again to Willem Elsschot. Practical objections and rules and laws. This law contains recommendations. Strictly legal — I am not a lawyer — a recommendation has a very wide margin. This needs to be clarified in order to provide legal certainty and the recommendations do not give rise to procedures, nor to braking and steering with the brakes. In that case, it would be an empty box. The use of medical rules or guidelines is a concept that, in my opinion, is legally better anchored.

Responsibility of the patient. It was again Mr. Verhaegen who referred to this with quite strong examples that I would not dare to put in this way. We may not have stopped so much on this, but the incentive to responsibility the patient is indeed in the present bill. The patient is informed, among other things, about the expenses and has the right to information from the health funds on the price and quality of what was prescribed. La carte vitale in France is an example. I’m not saying that we should go so far that every patient should have a card in his handbag or wallet stating how much he/she has already spent on the health insurance this year. I do not say that. However, information is another story. A well-informed patient costs less and gets better care. This is another statement that I have already defended many times.

As regards the moratorium, I agree with Mr Bacquelaine’s argument. The exceptions contained in the law can seriously undermine the moratorium. The fact is that the conflict within the hospitals must be settled and stopped before there reigns trust and one can continue to work together: administrators and providers, in a positive way and without fear of being held accountable for what they have not done. This point also has to do with the transparency of hospital funding which also requires a whole debate both on medicines, discounts and medical equipment. Transparency of hospital financing coupled with greater legal certainty is just a necessity. This law allows for steps forward in this regard.

As a preliminary point, I would like to express a concern regarding Article 11, Mr. Minister. Of course, we are in favor of the rational use of heavy equipment, within the rules of care. However, I would not like to see that the prohibition of offering certain concerns inhibits the development of new concerns, medicines and techniques. Thro ⁇ the country, we have “centres of excellence”, but we must not hinder our surgeons from doing their work.

The introduction of the Prime Minister has already caused a lot of controversy around this topic. If the article 11 of this law effectively prohibits the use of new techniques that have not yet been recognized, we will soon end up in a two-speed medicine. Those who can pay will then get care abroad and foreign patients, for whom the new law does not apply, may or may undergo those new techniques. That may not be the intention, and it may not be your intention. Article 11 was written for illegal heavy equipment, but should not provide for new techniques — in which we are good — to be banned.

I refer again to the rationality of extra-mural treatments. This too needs to be revised. The day hospitals are overcrowded. It is precisely in the day hospitalization that there are waiting lists. We need to re-examine it because this increases the patient’s comfort. In addition, limited recognition of operating rooms and staff can positively affect performance outside hospitals. This has consequences for the hospital and positive consequences for the RIZIV budget. Enabling extra-mural daily hospitalization is a track that we must treat in Belgium.

Many contact points have already been created, but I would like to call on everyone to notify the Minister without hesitation if a certain intervention or treatment cannot be initiated because of the law.

This should not be a formal point of reference for me, but the threshold must be removed. One must dare to report it, one must dare to say that according to the law one cannot treat a particular patient for a particular condition because it is not recognized or programmed, while one can help those people. A kind of contact point in which you are informed at least without penalization of the provider and without penalization of the hospital, is, in my opinion, at least necessary in this.

I will finish with a final quote. I picked it from a group of professionals in whom confidence has become very low, especially the journalists. It didn’t happen to us, but in England. One of the tabloids of those journalists wrote the following: "Everybody hates us and we don't care." Well, this is something I ⁇ 't want to see happening in our health sector. I ⁇ ’t want to see this happen because the double of “we don’t care” could mean “we become indifferent”, but much worse, Mr. Minister, it could mean “we don’t care anymore, we don’t care anymore, or we’re not motivated anymore.”

From the trust polls, there is another sector in addition to education in which people have or had confidence. This is precisely the health sector because they have the freedom to choose who to be treated with and because, in addition, the doctors have the freedom to choose their own therapy. This confidence, Mr. Minister, is one of our most beautiful pearls in our health policy. I hope that this law will preserve confidence.

This can even be done with the powers, Mr. Goutry. I belong to a category of people who have confidence, including those who will take responsibility in this matter. I would like to give that pearl of trust both to you and to the actors and stakeholders in the sector who are facing a huge task.

Thank you Mrs. I have let you finish, but there is a small note from Mr. Goutry. Then comes the Minister.

Mr. Speaker, I just want to add that our colleague spoke nothing, no word, about one of the backbones of the story, in particular the powers. Previously, they were quite destructive about it, Mrs. Avontroodt and Mrs. De Block. They have exhausted themselves to say on all possible forums of doctors and others that those powers were unacceptable and that we had to formulate suggestions ourselves, and so on. Now they swallow it and they say: well, that was for the press, but here in Parliament that doesn’t matter.

Mr. Goutry, I started by quoting Willem Elsschot. I projected that on the powers. I have begun by saying that no member of parliament can be happy with powers, neither do we. That is obvious. Their

But I have also said that there is a process of growth and that through the debate and through the confrontation and through the conversation — you know that one is working on the various forums — one could submit exact proposals to the minister. It has grown from below, as we always work. We know that any policy that grows bottom-up has the most chances of being sustainable, Mr. Goutry. In this, there may be an evolution in thought. The powers? No, we are not happy with that. But it is only for one year. So, we see it.

All the speakers — they were with 9 plus the reporter — have been addressed in the debates that have now lasted a little 7 hours. Let me briefly comment on the Minister. I will see when I suspend the meeting afterwards to do the article-by-article discussion. We will see that in a few moments.

The floor is to you, Mr. Minister, at the end of this general debate. I please please.

Mr. Speaker, I would like to begin by telling the last speaker, to whom I pay tribute for her very nuanced remarks, that it should not be possible to transform the English saying she read in a tabloid "They hate us because..., and we don't care" into "They hate us because we don't cure"!

Today, measures need to be made in the healthcare sector and, overall, in the secu sector, where the health care component plays a significant part. Today, a number of things are not going well. Is it because of the economy or management? We need to be much more nuanced. Indeed, if really, this was the case, if the acts of management or the conjuncture were exclusively at the origin of these problems, one could believe that all the predecessors, going back to JeanLuc Dehaene, had taken the necessary structural measures for the boat to move quietly on the waves. This is not true because the healthcare sector will continuously be subject to questioning needs.

I think there is a constant need for structural reflection on the changes to be made. I will give you a few numbers. If we compare the situation of Belgium with that of neighboring countries and countries with developed social security and health care systems, we are still in relatively acceptable order of magnitude. I take the figures that have been issued by the Committee on Ageing whose work is not negligible. To establish a comparative average on 2001 - but we could have similar comparative averages in the order of magnitude on the financial year 2004 -, Belgium is, in the European average, below France and Germany and very slightly above, now, - it was below at the time - the Netherlands. We are well, in order of GDP size, in comparable spending.

Another comparison interests me: go look in health care for the component "drugs" and see how we behave in Belgium compared to other countries. What do we see? If one makes a relationship of the cost of the drug to GDP, it is noticed that in Belgium, the cost of the drug is approximately 1.6% of our national wealth. Germany has a very similar rate. In contrast, the United States is at 1.8 percent. France alone is doing better than we do in Western Europe with 2%.

If you now establish a relationship between the healthcare budget in GDP and the cost in the healthcare budget, you will see that France is still at the forefront since it devotes approximately 21% of its healthcare spending to medicines, that Belgium comes immediately behind, before even the United States that I cited just before, with 17.7% of its healthcare budget devoted to the medicine policy. by

But there is a nuance. If we are today among the countries with a reasonable average of spending compared to our neighbors and countries with a comparable social security and health care system, and if we know that some countries with which we sometimes compare, for example beyond the Atlantic, have higher overall spending on health care while spending on medicines a smaller part of their spending on health care, it also means – and you will see in what this nuance my word for the future – that sometimes, in some cases, the use of the drug in Belgium can prevent pathologies that could be costly if they were treated otherwise. So you hear here a minister speaking with a great sense of the nuance of the pharmaceutical sector. by

I will now communicate to you a few gross figures on the evolution of expenditure. If we look at what we know from 2004 and which greatly interests the members of this assembly, we expected a surpassing of the order of 634 million. The news is not good but it is not as negative as the one we expected since the surpass is 513 million. Let us now examine what the reality of this number is made of.

It could be said that there are three equivalent blocks of the order of a fifty million. The first concerns the policy of aging (rest homes and rest and care homes). The second concerns the maximum to be charged (MAF), a point that was recently addressed by our colleague Mrs Avontroodt. I simply point out and without prejudice to other reflections that in the case of global excess, the MAF being a correction system, it is obvious that there is also excess in the MAF. The third package of 50 million consists of medical fees. This means that contrary to what the medical press had to hear recently, there is, unfortunately, an excess in medical fees. I would have preferred that this would not be the case. by

Next to this, there is a large package, 75% of the surpass, which represents 384 million euros and no longer 372 as Mr. said. Dresses, attributed to the medicine policy.

I will spare all the speech I could have made to summarize the law we are going to vote for. In the report that was made recently, the important provisions were recalled. I go above the Solidarity Fund, above the various practical arrangements that do not deserve further comment.

On the other hand, with regard to the planning of the care offer, as soon as reference is made - and this has been addressed by several of you, "ab initio" by our colleague Goutry, also by Mr. Goutry. Bultinck, on the question of care areas, which I call "chalandise" areas rather than care areas, I recall that this is not a perfectly defined geographical boundaries, as was the case in particular in the Flemish decree creating the "zorgregio's".

We are much more here in a logic that must make a number of deployments of the medical offer in all its forms, not only the hospital form, correspond to the needs of people. When we talk about heavy medical devices, I have no ambiguity on this point, not even in the note that our colleague Bultinck recently read, stating a response to a written question asked earlier. It cannot be said that there is a need for programming that is based on the objective state of needs without, at the same time, taking tools that enable compliance with this programming. Now, we were in this situation of particular hypocrisy in Belgium where the federal state had the faculty to develop programming tools but, on the other hand, it was not able, when it could observe excesses, to take action.

However, I have to say that there are incorrect numbers that have been cited recently. Since the time has come to correct them, I will do it.

As for PETs, we are here, in international comparison, in a situation that is not as dramatic as that. The program provides some 13 PET for the territory of our great country. It should be noted that, internationally, this is 1 million inhabitants per PET. In other words, if we applied this rule to our own territory, we would already be beyond in terms of programming. We have been more generous. I will add that no clue, since you know that the Kenniscentrum is reworking this matter, already allows us to predict the outcome of the reflection in terms of relief or not. I’m not going to do programming — and I’ve heard it on this tribune just recently — that doesn’t actually respond to needs and logic based on science and also on cost control and efficiency. These are parameters that are, for me, at the center of the debate and that also answers our colleague Drèze, although I cannot be more precise at the moment.

It was said that there were 5 PETs in Flanders and 14 in Wallonia. Of the approved PETs, there are 7 in Flanders, of which 1 is taken in the linguistic role in Brussels, and 6 on the French-speaking role of which 3 in Brussels. Where are we in PETs that are not in the logic of programming? We currently have 3 PETs in Brussels, 3 in Wallonia and 1 in Flanders. These are the objective figures that I have at the moment.

This law will allow to reactivate the debate on programming, to give it a new relevance, with the tags that have just been placed here, with the ongoing studies that will help us to define the needs. I immediately reassure Yolande Avontroodt because effectively, the concern here is not to make savings. It is not exclusively and in a obscure way to do economics. It is to respond intelligently in health economy to the needs of the territory that is our own, by covering it with an ad hoc apparatus in the indicated quantity.

I will return to the other questions raised during the speeches. Have we experienced a mitigation of the public procurement system? I sincerely recall, as I always did in the committee and when I was able to talk about it in the plenary session during current issues, that I have never claimed to be a supporter of the full implementation in our country of the New Zealand kiwi system. Why Why ? For those who are distracted, there is a slight difference between New Zealand and Belgium. If we had a system in which we create, through the mechanisms set up, external air calls, the borders of Belgium would be quickly crossed! As for New Zealand, those who go to Japan for swimming are still less common. We must know that we are not an island, we are not in a situation where we can adopt regulations independent of the particular European context in which we are. So what we have done is adapting, it is taking provisions that translate into our domestic law, an interesting reality.

It is truly a revolutionary mechanism for our way of working. We’re going to make bidding, though limited – I look in Mrs D’Hondt’s eyes because she knows what I’m going to say – to drugs today out of patent. However, we have given, as several speakers have reminded this tribune, the faculty to the drug reimbursement commission to detect all innovative counterfeits, in order to correct the shot. It is unacceptable that today a certain pharmaceutical industry — I’m not targeting the whole pharmaceutical industry — travests behind a number of allegedly innovative products of old molecules whose shape has been modified or uses new molecules but which do not bring therapeutic added value by making them pay much more, not only to society but also to individuals, you and me, the citizens of that country who must buy them. So we have a mechanism. We even went further. We have not talked about this in this tribune, but I will remind you because it is included in our texts. We also envisage that, in some cases, when a number of derivative elements in the product, even under patent, show that there is disguise of the actual innovative value of the product, we give ourselves a field of action. That is to say that we are far from a scheme where we would have given in to the pharmaceutical industry.

I would like to recall the negotiation elements put on the table with - to respond to a request made by our colleague Mr. Dresden - a few budget points.

We agreed to take the risk of ⁇ ining patented molecules within the scope, as part of tender calls and better repayment procedures that we could put in place as part of group reviews. And we asked the pharmaceutical industry what it brought us in return. First of all, I mentioned it recently. This cash consists of a new sum of approximately 23 million euros on an annual basis. In the text, we have already envisaged two budget years. We arrive on an annual basis, beyond the "claw back", to a total of 150 million euros, which is absolutely new.

This is agreed by the industry for the simple reason that it itself observes the current evolution to see the increasing trend.

There are also the 40 million euros that we will seek today at the level of old medicines by lowering the age limits; we go from 17 years to 15 and from 15 years to 12. If we apply these 40 million on an annual basis over a third of the year, that represents about 13 million. Article 61 of this Regulation provides for this.

Another element I could figure out is the expansion of the possibility of using the repayment amounts in various forms; this represents 35 million savings on an annual basis, or 17.5 million for a six-month period. Finally, when the rate of price decrease for old products or generic products is increased from 26 to 30%, this represents some 24 million euros on an annual basis or, over a six-month period, as will likely be the case for 2005, an amount of 12 million euros.

A few minutes ago, a question was asked to me in the tribune. I was asked if we would not have had an interest in going further by moving from 30% reduction to 40%. by

In this regard, read, and mr. Bultinck recalled it recently, the reaction of the industry that makes generic products. She says: “If you push the decline rate too far, you create conditions such for us that we will no longer be able to produce our generic drugs under sufficiently cost-effective conditions. We have to close the store.” In this case, the prices of old non-generic medicines will no longer be pushed down as we will no longer have the capacity to produce those medicines. by

Mr. Bultinck, when I see the dissatisfaction of both the industry producing the traditional brands and the industry producing generics, I say to myself that we must be in the right way since we have everyone on our back. I will not, as our colleague Avontroodt said recently, satisfy myself with having everyone on the back. However, when I see that these arrangements do not satisfy these two segments, I say to myself that one must probably be in the right; I believe it very sincerely. by

I would also like to give some additional information to some colleagues who have asked specific questions.

In particular, I was asked just recently how the cost of the social agreement was integrated into our 2005 budget. I reassure you: the Social Agreement does not produce its effects in 2005 on the accounting level. It is estimated that the costs are imputable at the end of the last quarter, on 1 January of the following year. This does not mean that there should be no arrangements to allow the payment of this social agreement, one of the reasons why we propose to adopt this law in the state.

I would like to conclude on one point that I find important, namely that in all the authorisation provisions, we wanted to set a precise scope. We are not in the presence of an unlimited authorization in terms of time, on that of matters that are clearly indicated or on the modes of control since it is also planned that we will have to report regularly. Furthermore, in final, if the proposed procedure is followed, in order for the measures to continue their effect, this will need to be ratified by a law in that same assembly.

I am also not happy to have to take more radical measures. But if today I am at the tribune with great conviction, that is not to say that we must equip the country with structures that bypass the traditional negotiation procedures. On the other hand, I think that it is useful, if we do not have a result within the desired time, to be able to dispose of this instrument, of this "butt behind the door", as some have said allegorically. Without prejudice to the reasons why the figures are already better or less bad than we imagined in 2004, as soon as we launched the debate on economic measures — a debate that we will continue —, an awareness gain could be observed in the specialized press or on the ground, when we meet specialized actors.

We will continue in the same direction. We have a few months ahead of us to concrete and I hope that I will still be able to rely on the parliamentary initiative in addition to all that I can implement from this authorization mechanism that you will vote for.