Proposition 52K1492

Projet de loi portant modification de l'article 157 de la loi relative à l'assurance obligatoire soins de santé et indemnités, coordonnée le 14 juillet 1994.

General information ¶

Submitted by

CD&V Leterme Ⅰ

Submission date

Oct. 16, 2008

Official page

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Status

Adopted

Requirement

Simple

Subjects

administrative sanction health insurance

Voting ¶

Voted to adopt

Groen CD&V Vooruit Ecolo LE PS | SP Open Vld N-VA LDD MR FN VB

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Discussion ¶

Nov. 20, 2008 | Plenary session (Chamber of representatives)

Full source

Mr. Speaker, colleagues, the present bill may be of a technical nature, but it still regulates a number of important healthcare matters. Therefore, I will provide a brief report.

The first part includes improving the accessibility of medical care. This is an important priority for this government. Four improvements are proposed in the transport of sick persons. Also for the urgent transport by ambulance, a legal framework is created to intervene in the costs. A number of technical improvements are proposed in the context of the integration of small risks and of the social status of self-employed persons in connection with a compulsory health insurance. There are also some improvements to the law on the maximum invoice.

An important chapter is that on the reform of the revaluation of the status of the adviser-physician. This is motivated by the finding that 40% of the approximately 280 counseling physicians are currently over 50 years old. Therefore, one will be forced to make a significant effort in the coming years for the necessary replacement. The government wants to make that position more attractive by updating the assignments, providing adequate support and revaluing the status financially.

Furthermore, a High Council of Medical Masters Directors will be established. The draft law also introduces a number of priority rules for the registration of persons in charge of the titularis in the unified system of compulsory health insurance for self-employed persons and workers.

The composition of the National Council of Nurses, after the approval of this draft, the Federal Council, is adjusted, thereby better regulating the representation of the nurses.

Furthermore, there is a loophole on the profession of emergency service provider-ambulancer. With this draft, the Government aims to protect and define the profession and create a legal framework for the activities linked to that function.

We had a discussion on this in the committee.

Mr Gilkinet pleaded for more consultation with the doctors on the reform of the status of counseling physician and the threatening medical shortage. He submitted amendments, but they were not held.

Mr. Bultinck questioned the dual role of the counseling and control physician on the one hand.

Mrs Becq emphasized the importance of the scheme for the intervention in the travel costs for hospital transport, but also asked for attention to specific situations such as co-parenthood, a problem recognized by the Minister and in which context she is open to solutions.

Ms. Musin emphasized the strengthening of solidarity in medical care insurance by abolishing the contributions for certain categories of pensioners and widows.

The amendment of Mrs. Maya Detiège and Mrs. Christine Van Broeckhoven, explained by Mr. Hans Bonte, was the subject of discussion but was not held. The amendment concerned the abolition of the honorary salary supplements for double rooms and its limitation to 100% of the commitment rates for single rooms.

The Minister gave to this problem to be affectionate but to choose consultation in order to gradually reach a sustainable result.

Within the framework of the new duties of the counseling physicians, Ms. Lecomte requested the attention to respect the principle of therapeutic freedom of the healthcare providers in the exercise of those duties. A majority-party amendment was submitted in this regard, which was withheld.

Ms. De Block emphasized the role of the counseling physicians and emphasized the importance of consultation on the subject between the counseling physicians, the insurance companies and the business physicians.

The bill was eventually adopted with 12 votes for and 2 abstentions.

Mr. Speaker, Mrs. Minister, dear colleagues, a law with various provisions is always a somewhat indigest legislative text. The one we discussed in the Public Health Committee, and which is submitted to us today, is structured in such a way that the proposed provisions meet three clear and precise objectives.

These goals strengthen the foundations of our healthcare system, namely improving accessibility, strengthening good governance and consolidating the quality of service providers and their services.

I will illustrate these guidelines with a few flagship measures.

The first concerns reference amounts. The tariff differences that hospitals may apply for standard and frequent medical and surgical services are, at least, unjustified, but above all unjustified. The system established in 2002 to penalize financially and a posteriori hospitals with abnormally expensive practices does not work. The Minister’s willingness to address this problem must be emphasized, especially since this financial penalty cannot be taxed as beast and evil. In fact, thanks to the proposed changes, each hospital will have the possibility, during the year, to correct the shot through the "feedback" system now planned.

Another significant change is the inclusion of pre-operative outpatient examinations in the comparison system for these reference amounts.

These measures will effectively combat unjustified tariff disparities that – remember – are at the expense of patients and abnormally strike the healthcare budget.

I thus arrive at another iconic element of this project: the legal basis that will finally allow INAMI to recover the premiums paid to an agreed provider who, despite its obligations, does not comply with the tariffs set in the agreement.

I would like to emphasize this point which, on the one hand, will put an end to the unacceptable, illegal and immoral practices of certain providers and, on the other hand, will offer more guarantees of tariff security to the patient who, by choosing an agreed provider, should benefit from the tariffs provided for by that convention.

Furthermore, in order to improve the quality of the services and thereby enhance the safety of patients, I find it important to establish a qualitative control of the firms responsible for installing gas dispensation equipment, such as oxygen. This measure will be implemented through the certification of those professionals who will also have an obligation to maintain the devices. Patients will be given reliable instructions for their use.

Always in this concern of guaranteeing and increasing the safety of the patient, and at the same time having the heart of protecting the service providers, the project will result in significant changes in the profession of ambulance rescue workers. By regulating it and, above all, by precisely determining the acts of these persons, the minister intends to offer legal certainty to ambulance rescuers – security that they do not enjoy today, which can be obviously harmful to them. This issue has been the subject of long debates in the committee.

For my group, however, it is clear that, given the importance and peculiarity of this profession – should we remember that these people act in an emergency situation and often in a manner not negligible? It is important that it is recognized and encapsulated. It should not be forgotten that this measure will not only strengthen the legal certainty of these professionals, but will also contribute to the safety of the patient.

Finally, with regard to the profession of nurse, some provisions aim to adapt the National Council of Nursing Art, which is also renamed "Federal Council". The adaptation of this Council to the current situation of the profession in question deserves to be emphasized.

This fundamental but yet so poorly valued, so poorly recognized profession will be the subject in the near future of an attractiveness plan announced to us by the Minister and of which we look forward to the first achievements.

As regards more specifically the representation within the Council of the different practices covered by the nursing profession, I would like to recall the responsibility of the sector itself which must take into account the interests of the whole profession and must therefore balance the different sensitivities in its representation within the Federal Council.

Finally, without weighing on the problem, I allow myself to warn against sectorization, the specialization beyond health care from which the nurse profession is not exempt.

Mr. Speaker, ladies and gentlemen ministers, ladies and gentlemen representatives and ladies and gentlemen of the public, my amendment relates to Article 10 in the draft law adopted by the committees, the former Article 13. The article covers the financing of the centers for human heredity. It is a new amendment that has not been submitted to the committee.

The Minister proposes to change the financing of the centres for human heritage in Belgium from the current financing, which provides for a fee per provision, to a global intervention through an agreement. For this purpose, the Minister wishes to supplement Article 22 of the Health Act with a provision 18°, which stipulates that agreements will be concluded with the centres for human heredity, recognized on the basis of the criteria determined by the King, for benefits excluded from receipt through the nomenclature of medical services referred to in Article 35, and which relate very specifically to hereditary diseases. According to the Minister, the RIZIV Insurance Committee will be given the appropriate instruments to intervene in the costs of this complex matter.

Mrs. Minister, although I understand your concern not to impose an unlimited and uncontrollable burden on the public health budget due to a very sharp increase in genetic testing, I still worry about the vague wording of the added provision. Let me explain that.

At present, the centers for human heredity are compensated, on the one hand, by a subsidy and, on the other hand, by a fixed fee, which is limited by steel decomposition and an honorary fee per provision for the counseling – the genetic counseling – by a genetic counselor.

The steel withdrawal fee is a fee given for either a DNA test or a cytogenetic test, a test on chromosomes. Now, the government wishes to move away from this fee per delivery through the nomenclature of medical benefits and to move to a global intervention.

In the explanatory note to the bill, the Minister says that due to the very rapid evolution in medical genetics, a subfield of medicine, it becomes increasingly difficult for the compulsory health insurance to meet the many new benefits in a timely and appropriate manner, because the procedures for realizing new nomenclatures would take a long time. It also concerns very specifically often rare, but very specific benefits. These are also time-intensive and intellectually demanding services, such as genetic counseling, which is an individual counseling and requires a lot of time because you have conversations with patients and their family members about a genetic predestination or a genetic risk. This is very difficult to convert into a single uniform fee per provision.

That increase in medical genetic testing comes thanks to scientific research. In this way, medical genetics is also experiencing an explosive development and especially the number of genetic tests will increase in the context of genetic counseling for hereditary diseases or hereditary risks. These tests are becoming more and more complex and the diseases for which they are testing are also becoming more and more complicated. In genetics, one is actually evolving from the so-called simple disease, where a hereditary defect has occurred, to what we call the complex disease, a hereditary risk profile in which one must test different genetic markers.

The translation by the genetic counselor of this yet very complex matter is not easy. It is not easy to explain that to a patient, who is usually a leech, let alone to the relatives who are at risk, let alone to the treating doctor. Even in the training of doctors today still very little attention is paid to knowledge about genetics. In Belgium, there is no specialization in medical genetics.

The Federal Knowledge Centre for Healthcare has conducted a study, specifically on the organization and financing of genetic diagnostics in Belgium. This study was completed and ⁇ in 2007. A number of conclusions were made. The first finding is that there is currently no effective limitation in the number of genetic tests performed and charged. The only limitation may come from the geneticist who will decide when a test is carried out, or from the geneticists in the medical-genetic centers, or through the medical-genetic board. There is no limit on the number of tests. That is, on the one hand, very natural, because more and more tests are available and that these genetic tests naturally serve as a service to our society. However, it is noted that the genetic does not always play a proper role in this. I will return to that later.

There is already coordination with regard to genetic testing: there are arrangements between different centers to avoid a number of tests being offered in each center, ⁇ for those that are used more rarely. Why are genetic tests now paid per test? Genetic testing is today the largest source of income in medical-genetic centers. That source of income is also used to provide for the advance, which means doing research on new genetic testing and on new diseases. This also means that the volume of the number of genetic tests in Belgium is somehow kept a little higher than is strictly necessary in principle.

The second finding is that the counseling, giving the genetic advice, is compensated too low by the RIZIV. There is too low reimbursement for this genetic advice by the genetic advisors. This means that the performance of the genetic tests is usually much higher than the genetic counseling itself. This is a financial loss. Genetic counseling, in principle, means that a patient and family members are sometimes in conversation for an hour or two. No specific complex interventions or treatments are applied: it is a conversation between the patient and family members with the genetic counselor.

So it is a long-term contact between the doctor and the patient. It is lowly repaid and only a very limited number of genetic advice is issued per session. However, genetic counseling is one of the most priority tasks of a medical-genetic center, especially in the future, as one will be able to detect the genetic predisposition for life-threatening and serious chronic diseases more and more. The importance of genetic counseling will continue to increase in the future. For example, I think of creating a genetic risk profile for Alzheimer’s dementia, but also, for example, a genetic risk profile for diabetes and other diseases associated with ageing.

There are already websites in Belgium where individuals and doctors can request genetic tests. These tests are usually carried out abroad. By taking advantage of this offer, one bypasses the medical-genetic advice. There are also self-test kits for DNA. In this way, medical-genetic advice is once again bypassed. However, precisely the medical-genetic advice by an expert is very important for the guidance of patients and family.

The current article 10, and the current formulation added by the minister under 18, does not make any choice in spending the cash flows to those centers. It would be better to fix this legally and maintain large policies, because then there would be more attention and money going to the genetic counseling, with on the other hand a restriction of performing the genetic tests themselves, because performing those genetic tests can be done today with robotics, on large platforms, with large numbers. The prices are very low, much lower than the prices charged today. Today, the price of these genetic tests is kept artificially high. A DNA test, for example, costs per test, per sample, 300 euros.

Given the sharp increase in genetic diagnostics spending, the government needs more information or has more rights to information than the current existing annual reports. It is important to know how the funds are used and how they are distributed across the different categories, on the one hand the genetic advice and, on the other hand, the genetic tests and possibly the global subsidy of the center itself.

Comprehensive, retroactive analyses, such as those carried out by the KCE, can only partially map the activities in some centers. Not all information is available. It is also not made available, not even for the report that I have already mentioned. There should also be much more room for transparency.

This requires standardized, annual, public reports with a complete list of all the tests carried out as well as other activities per center. It is also important to indicate how many tests were done and how many genetic opinions were issued.

This means, in principle, that for each medical-genetic center a separate accounting should be drawn up. Thus, the aforementioned separate accounting, which directly relates to genetic testing and genetic counseling, can also be included separately in the financial statements of the centre, so as to make a clear distinction between the provision of genetic services, on the one hand, and the scientific research carried out in such a centre, on the other.

My amendment proposes to add to paragraph 18, which was added by Minister Onkelinx and as it is known to us from the bill, a number of paragraphs that reflect my recently expressed concern. It is about the possibility that genetic counseling would be further pressured. The additions also come to the benefit of the genetic tests themselves.

My proposal for the addition of the two aforementioned members or paragraphs is included in the rounded text. It means that I ask that the agreements to be concluded with the medical-genetic centers may provide for the payment of a compensation that covers the costs of the genetic tests and that also covers the costs of medical-genetic advice. The agreements shall also specify the circumstantial modalities according to which the aforementioned benefit is granted.

According to the proposal, the Minister shall establish the annual amount of the benefits on the basis of criteria determined by the King. Those criteria shall take into account, in particular, the cost-efficiency and quality of the test procedure and the quality of the complex medical-genetic advice.

Each centre shall then, according to the criteria determined by the King, annually prepare a report with a financial report and with the complete list of all the tests carried out as well as of the other activities per centre and their volume.

The above is the purpose of my amendment.

Mrs Van Broeckhoven, I thank you for your first presentation in the Chamber.

Mr. Speaker, Mr. Van Broeckhoven’s speech was interesting, as always. It is a field specialist who can usefully enlighten the Parliament.

His proposals go far beyond what is proposed in this project. I think we could work on it as part of a draft or a bill or a proposal for a resolution, then we could take a look at everything related to human genetics.

Your proposal was interesting, but your proposal goes far beyond the subject of this bill.

Mrs. Minister, thank you for the explanation.

What I wanted to express here is that despite the technological developments in DNA – we can already do a lot in DNA and I am indeed also a DNA specialist – a medical-genetic center must primarily pay attention to the provision of services to society and that this provision of services involves precisely genetic counseling. We do not have any specific training for this in Belgium, you know. In the surrounding countries this exists.

It is a very complex matter and if one would limit the advice in time and number then one comes into a situation where people in our society are confronted with highly technological information about a potential hereditary risk and the fact that they do not know what to do with this information. Genetic testing can now be done through other routes, outside of the medical-genetic center.

It is therefore important that, in the preparation of this proposal, it is not to be left to the medical-genetic centers to determine whether the money should go to medical-genetic advice or to genetic tests. After all, we know that medical-genetic centers today use a large portion of this money to support scientific research. This is an important criticism. I’m not saying that they should not do scientific research, but I’m concerned about the loss of the importance of medical-genetic counseling to the people in our society, especially now that we can fully map the DNA.

Mr. Speaker, Mrs. Minister, colleagues, as usual, a bill of various provisions is indeed about various provisions. Nevertheless, there are many important chapters that deal with important aspects of health care. Therefore, I would like to briefly reflect on one thing.

First and foremost, I find it important and also wise that everything that was originally stated in the preliminary draft about the so-called nofault regulation, the error-free liability scheme for medical damage, has been cleared from the draft and that there will be a separate draft on it, so that we can discuss that important theme after studying, among other things, the financing in a good way. I think that is definitely the best choice. Only, Mrs. Minister, we will have to keep an eye on the fact that the Faultless Liability Act normally, with delay, comes into effect on 1 January 2009 and that we will have to postpone that law again, so that we have the time – which will probably be in the spring – to discuss the bill.

We were able to give timely responses in the committee. I would therefore limit my intervention to a number of major points.

I think, Mrs. Minister, that we must urgently hold a number of important debates on capita selecta from healthcare, including on nursing. By the way, you have announced a plan to increase the attractiveness of the profession. We will have to discuss this plan in the Chamber soon. This will be a good opportunity to talk about a number of things. For example, how far should we go in nursing with regard to special professional titles? With regard to the special professional skills, we must be careful not to go too far, so that we do not get too specialized nursing. As a result, we would lose a lot of polyvalence in basic nursing. We will undoubtedly discuss this following your plan.

We also want to talk about training. It is different. In Wallonia, the training takes 4 years, in Flanders it actually takes only 3 years and there are opportunities to become a nurse through what is called the continuing training, the fourth degree training. We absolutely wish that nothing changes and that we still retain A2 nurses and A1 nurses in nursing. Sometimes they have other responsibilities. A1 nurses typically flow through to the middle framework and take on responsible tasks, while we need exactly A2 nurses for basic care.

In the framework of the draft, we discussed quite important provisions related to the National Council for Nursing. It was a bit of an office that we could not obtain advice on the subject from the National Council itself, because at that time, for more than a year, it no longer existed. So we could not involve him in it.

Therefore, I have a number of concerns, which we will need to evaluate in the future. First, the primary nurses should remain sufficiently represented in the National Council for Nursing. If too many people with titles in nursing or with special abilities are enrolled, the National Council will also be an expression of this, and then you may lose too much the voice of the basic nurses in the National Council. We think that it is very important that we retain those voices, ⁇ given the fact that due to ageing there will have to be more care to the elderly provided precisely by those basic nurses.

It is also important that in the National Council for Nursing there are sufficient representatives of both A1 and A2 training. It is therefore positive that now also the nurses will be represented in the National Council of Nurses.

It is also important that the sectors are sufficiently differentiated and represented and can be addressed in the Council, such as the hospital sector, which is different from the home care sector. Home nurses will have completely different concerns, will have a different view of the policy, from their specific perspective, than nurses working in the elderly care, in rest and care homes. It is important that there is a good balance there, also in the future, in the National Council, so that they can also be addressed.

There should also be a good distribution between, on the one hand, professional organisations for nurses and, on the other hand, trade organisations. It is not yet clear how this will happen. In short, the trade union branch should also be able to participate in this.

There is a little fear that the National Council will count too many participants. A board with too many participants then does not work more smoothly or not well. Then there is the danger that too many affairs will be delegated to a smaller group, say the Bureau of the National Council, possibly resulting in a democratic loss. It is better to set up a working board with a balanced number of participants, who can give good advice and properly support the policy in the field of nursing.

What we find positive about the National Council for Nursing is that there is an incompatibility between the mandate of the Technical Commission for Nursing and the National Council. I think this is normal, good and even necessary. Furthermore, we consider the incompatibility between the National Council on the one hand and the Recognition Commission for Nursing a point of concern. Therefore, this recognition committee will have to be completely re-composed. Until now, the Recognition Committee also consisted of members of the National Council.

Mrs. Minister, in the committee we have voted in favour of the composition of the National Council for Nursing and we will do so at this plenary session. It might be important to make an evaluation later, to check whether that composition is good and balanced and whether each vote is in question.

As for the ambulances, I remind you of your commitment, Mrs. Minister. It is important to cooperate with Homeland Affairs because there is a overlap with regard to the fire department.

The Commission on the Statute was created.

It is also important that further participation in the working group is possible with the people involved in the field, so that we can reach an arrangement there that is truly useful and that responds to both the needs and the reality. We are there with a overlap in the fire department, a competence of the Minister of Internal Affairs. Therefore, we will ⁇ need to cooperate.

Mrs. Minister, for all clarity, you know that there has been a lot of heisa on the problem of the ambulance sector. I will not be cynical and will not talk about the division and the amendments of the majority, which will be withdrawn at the very last moment. I want from you the clear guarantee that with the sector and all the actors of the sector will indeed be consulted on the aforementioned Articles 80 and 81. That answer is very crucial. Otherwise, our group will submit amendments to those articles again. I would like to get a very concrete answer from you. I think this is crucial to prevent you from morally obliging us to submit amendments again.

Mr. Speaker, I am pleased that Mr. Goutry cited this loophole. We have been able to devote this to a serious and clarifying discussion in the committee.

Mrs. Minister, those responsible for urgent transport, the ambulances and the whole industry, by the way, will undoubtedly read this report with great attention.

You said that a statutory committee has been established and that is very good. We have already asked in the previous legislature for the attention of the volunteers, who take over the lion’s share of the urgent and non-urgent transport of sick people – which is of course a problem of the Regions and the Communities. For the quality of the emergency assistance on the ground, this is absolutely necessary. I hope you will succeed in improving and recognizing this status so that more resources can be released for this sector. In this draft, it must be stated that it is only the ambulances employed by the fire departments and not the volunteers.

Specifically, this applies to ambulance rescuers. The purpose of the bill is very precise and important: allowing these ambulance rescuers to be covered for the medical acts they are supposed to practice as part of emergency medical care. It was indispensable.

That said, you are right: the problem of the status remains whole. It is not only about my competences, but also the Minister of the Interior and the Regions. But I committed myself to ask for the constitution, with the professionals, of a working group. Of course, follow-up has been given to this commitment.

This is, in my opinion, a reassuring and important statement. I think no one doubts that ambulances have an important task, especially in urgent cases. These people must, of course, receive adequate education and have sufficient expertise. That is obvious. The debate should also be opened to non-urgent transport, with the problem of competence distribution.

It is important that we initiate this law and at least begin to provide a legal basis so that formation and better support are possible. On the question of how that statute should be drawn up, we get clearly from the Minister the answer that it can be considered further with the interested parties, together with the Minister of Internal Affairs.

The second chapter deals with deontology. The draft concerns the so-called provincial medical commissions, which are given extensive disciplinary powers with respect to the healthcare providers with a criminal register, who thus would have committed criminal offences and whose visas must be able to be seized. In this context, we have noted that we can understand that a regulation is necessary. That is a gap. We have only asked to be careful, because the medical commissions are already overloaded. When will they be able to do that? Furthermore, it is new for the medical commissions, which so far did not act really repressively, disciplinary, that they now also have that power. We have agreed with the Minister that the debate in the future will nevertheless need to be extended to the reform of the Order of Physicians and to the establishment of a high council for deontology on health care professions. I think we will then, at a suitable time, have to resume the debate in that context.

A third chapter focused on the screening and detection of diseases, which is closely related to prevention. Hence the constant remarks on the powers. Prevention is within the competence of the Communities. Mrs. Minister, we will undoubtedly return to this during the discussion of the Cancer Plan where prevention, detection and prophylaxis are an important part of it. We have noted in the committee that the screening should be organized in close consultation with the curative aspect. To do this, the Communities must be aligned to the federal level and vice versa. This is a matter for the interministerial conferences, so that the prevention and prevention policies to be conducted by the Communities can be coordinated as well as effectively as possible.

We have added that in the further discussion of the state reform we must dare to think logically. With regard to the key branch of health policy, prevention which is now within the competence of the Communities, we must in the future very consistently endeavor to make the competences on prevention and detection homogeneous so that a very efficient health policy can be pursued. We will continue to follow that position.

This is part of the debate that we need to conduct on the communitarianization of personal matters. For me, the most homogeneous and most efficient level is the best level.

Mr. Goutry, you undoubtedly know what I will say. Does this now mean that on behalf of CD&V you still believe in that major state reform? I am pleased to note a slightly more principled attitude. Even CD&V says it has been won for the defederalization of healthcare.

What you say is important. You are now in a majority with a minister in the post of Public Health and Social Affairs whom everyone knows that she is there to prevent the conversation about the de-federalization of health care from just beginning.

Mr. Bultinck, I must stick to the context that the law allows me. I never let myself be persuaded to endless debates or expansions.

I repeat what I said. There must be a homogeneous competence in prevention, prophylaxis and detestation so that we can work in the most efficient way in the future.

I come to the medicine chapter. This subject is present in almost every program law and in every law various provisions. This is also important. It is an essential part of health policy.

Also on this point the Minister said that we should continue to debate this matter in the future. We must also look at how to ⁇ the best cost price for medicines, primarily for the patient, but also for the health insurance, through price-volume contracts, public procurement and control and comparison of prices.

Therefore, group-based revisions and individual revisions are also important. We have worked on this further. We are behind it. We need to clean up the drug policy so that we can ban as many unnecessary medicines as possible.

We must especially be able to make price comparisons between medicines that ultimately have the same active ingredient and sometimes very different in price, which in fact is very illogical.

Finally, there is another important part about hospitals. We will soon decide to apply the Reference Behavior System. This law has been in place for five or six years, but it has not yet been applied. We have decided that in this regard we will not rely on the reference year 2003, but on the year 2006, as this will lead to a better system. That is important.

I repeat, on behalf of our group, that we are not only for a malus system in which outliers, those who make expenses that are irresponsible within hospitals, which would not only have to repay, but that those who perform well, do their best and carry out a good policy, would have the opportunity to be rewarded as an authority or hospital with an incentive. This is a type of bonus/malus system. We need to keep this debate open in the future.

Finally, there was also a talk about supplements in hospitals. Especially for the colleagues of the sp.a, I would like to point out the importance of the fact that now again will be legally stipulated that supplements can no longer be requested in two or multiple rooms. This is important for the new management team. As you know, there has been a time before we came into the opposition at the end of the 1990s, in which we even legally stipulated that only very limited honorary supplements could be requested in a single room. We did this then with Mr Vermassen and Mr Lenssens happier. Unfortunately, we have had to experience that Minister Vandenbroucke then abolished that arrangement because he wanted to have the hands free to reach an agreement between doctors and hospital funds. We have always regretted that. We have always submitted an amendment in the opposition period in order to abolish it. Now this has happened. You want to go on now. Amendments have been submitted in this regard, but please be pleased that we have now achieved this. We will see later how we can take further steps in this area.

Colleagues, this is an important bill with important implications for people who are dealing with healthcare problems. There are important chapters. We receive from the Minister the commitment that we will continue to discuss this with each other and that we can evaluate the matters that are decided here. In that sense, with this government, under the leadership of Ms. Onkelinx, we can step by step build on a good health care policy of which our people can only get better.

Mr. Speaker, dear colleagues, I make myself here the voice of Mrs. Salvi who participated in all the discussions of this bill in committee and who is unfortunately sick.

This law, which we vote today, presents several advances, in particular on access to health care. In particular, I would like to mention those that are very important to us.

First of all, with regard to the MENA, we are really happy to see fixed a forgetting of the previous law that will allow children of unaccompanied minors to also have access to health care.

The extension or creation of reimbursable benefits is also to be emphasized, as it will ease the family’s bill in serious illnesses. I take here as an example the refund of home-hospital journeys for children who suffer from cancer.

Another ongoing work is the strengthening of the integration of small independent risks into healthcare insurance. I will also emphasize the restoration of the priority rules for the registration of a dependent person. This has the merit of clarifying the situation of the dependants and this joins in particular a project that we had co-signed at the time. We know that improvements in this area need to continue. We welcome the various technical changes to this law that support this status of independent workers.

Screening – we have already talked about it – is an important lever against disease and, in this area, a new funding mechanism allows health insurance authorities to conclude agreements with the Communities for the payment of an intervention. At first, we wanted to have a package. Finally, after the various discussions, the payment arrangements provided by the Royal Decree allowed – we think – to satisfy Communities and Federal State and also to give transparency to the mechanism.

With regard to mutual partnerships, one measure seemed ⁇ interesting to us: the prohibition of distributing gifts during an affiliation. This leaves the citizens a great freedom of choice over the real role that the mutual must play.

A debate on the status of the counseling doctor and on the expansion of his competences took place in the committee. We have talked about this several times. On the one hand, this measure is a plus because it increases the attractiveness of the profession but, on the other hand, we have clearly understood the concerns of the medical sector regarding access to data. These concerns have resulted in a limitation of such access.

Finally, the question arose of a possible double role of the doctor-advisor, both counselor and controller. In this regard, as in other health law projects, it seems to us essential that this measure is lived on the ground in trust with healthcare providers, especially generalists. We would like to make an evaluation after the implementation of the project.

Another discussion – Mr. Goutry spoke about it – concerned the Federal Council of Nursing Art and the improvement of its operation. Indeed, the law changes its composition as there is an increasing diversity of titles in the nursing world. This adaptation should allow for a better representation.

We all know that a register of medical professions is ongoing. We expect him to give us a better picture of what exists in order to rearrange representativity in this Council even better. We will also be attentive to the valuation plan you plan, Mrs. Minister, for the nursing world.

Finally, I will point out another measure that holds us at heart: the extension of the right to social MAF for certain children with disabilities. This is an administrative simplification for the affected families. We welcome this approach.

Mr. Speaker, Mrs. Minister, dear colleagues, the bill that is submitted to us today contains a number of provisions aimed at improving access to care, and we welcome them.

For example, we pay special attention to measures relating to interventions in medical transport, in the travel costs of elderly patients who go to a day center, in the travel costs of parents of a child suffering from cancer and in the transport costs by ambulance.

I would like to stop for a moment on Articles 25 to 33 of the Bill, which aims to reform and revaluate the status of medical counselor. It is important to note that the new missions in the project give additional powers to the medical advisors of the insurance agencies but the debate we conducted in the committee is likely to reassure about the scope of these.

First, we note that for the first two missions, it is essentially a role of informing patients and doctors.

Secondly, the Minister confirmed to us that, in terms of medical examination, the current rules will not be modified and that it is not a matter of granting de facto to counseling physicians the prerogatives of INAMI inspectors of the medical evaluation and control service. It was important to emphasize this.

For us, what is primary is that we are not oriented towards therapeutic decisions guided by purely budgetary considerations at the expense of the quality of care and the therapeutic freedom of doctors. In this regard, we are pleased that the amendment we had proposed was accepted. In fulfilling their mission, the physicians-consultants of the insurance organizations are obliged to respect the therapeutic freedom of the care providers.

Regarding Chapter 10 of this bill, which extends in particular the composition of the Federal Council of Nursing Art, we reiterate our remarks on the proposed articles. While it is clear that the Nursing Arts Council must best represent the nursing arts profession by balancing the association of general practitioners and specialized practitioners, it also seems to us legitimate that the nursing arts practitioners at home are represented there as well as the hospital nurses, with this lack of parity between the hospital and the ambulance regularly denounced by the associations.

Similarly, it seems to us that in order to be fully balanced, this Council must take equitable account of the practice of salaried and independent nursing art. Understand me well: it is not about dividing the practice of nursing art, but rather to ensure that the different practices, whether they are outpatient, hospital, generalists, specialists, employees or self-employed, are correctly represented in a well-understood interest of making prevailing the particular terrain reality of each.

When preparing the composition of this Council, Mrs. Minister, you will have to make sure to find a just balance, because it is within it that the nurses will be able to express themselves and make their claims.

Finally, you will have to advance in the application of the law on the representativity of associations, which the latter awaits. Your department has been too late in the implementation of this matter.

In order to continue in the examination of this project, Article 61 deserves to be emphasized. It aims to enable the widespread use of electronic certificates for the granting of additional rights in compulsory insurance to children with disabilities. This is a major step forward in the direction of the administrative simplification that we wanted to highlight.

We also support unreservedly Articles 67 to 75 which aim to give provincial medical commissions the means to carry out the tasks legally entrusted to them. For the Reform Movement, and contrary to some statements heard on other banks, the action of provincial medical commissions is important. They benefit from local anchorage through practitioners. Through the contacts they maintain with the Order and the information collected within the province, their action is optimized. For control and surveillance tasks, for example, the management of live information is obviously of greater interest than the necessarily passive action of a distant central organ, such as a ministry as some desired – necessarily less engaged with the realities of the field. Furthermore, their reason for being finds an additional favorable echo among nurses and physiotherapists who do not yet have an order, since they ensure tasks related to these two professions, mainly in terms of the verification of diplomas.

It is therefore apparent to us that the articles in project are of a nature to perpetuate the action of provincial medical commissions, which we welcome.

Here, Mr. Speaker, Mr. Minister, Ladies and Gentlemen, are the various remarks that the MR Group wanted to make during this debate. I thank you for your attention.

Mr. Speaker, Mrs. Minister, colleagues, uncertainty, it is the feeling that prevails in many families today. Uncertainty about savings rates, about purchasing power, about retirement, about work and about the future. Security, that is what people today, more than ever, need, and ⁇ in terms of social security. Assurance that people can pay their medical care bills, assurance on the honorary salaries of doctors and other healthcare providers, assurance that they have access to quality health care. This security costs money.

The Sp.a is therefore satisfied that the government is willing to invest sufficient funds in health care. Our party recognizes that every day must be fought to maintain the growth rate of 4.5%. However, the balance is very fragile and where the budgets are threatening to disrupt, there must be intervention. Therefore, Ms. Van Broeckhoven and I submit three amendments again today.

The spending on medicines is swinging out again and intervention is unfortunately pressing up again. The causes have long been known. There is the phenomenon of ageing in which, I think, everyone is happy that people are getting older. On the other hand, there is the arrival of new technologies, which is also good, and the new, but still very expensive medicines.

For 2009 this government is therefore looking for 120 million euros within the pharmaceutical budget. There are two shooters. I will not deal with them all in detail because that is a lot of work. This includes class 1 and orphan medicines. As regards class 1 medicinal products, I would like to point out that there needs to be done much more thorough work of dealing with the enantiomers, the combination products, products that are very similar to class 1 products but are actually not worthy to be counted in that group.

As regards the orphan medicines, it is necessary – I have just talked about it with Mrs Avontroodt – that we look at how we will deal with that group of medicines, which have a huge impact on the budget. There are statements from, among others, Professor Dupont who said there is too little scientific research. On the other hand, there are the comments of experts who say that more needs to be invested. I think we will need to create a good framework because it has a huge impact on the budget.

A second determination of huge spending on medicines concerns the hospital sector. The share of hospitals exceeds more than 30% of global spending on medicines. In 2007 it saw a growth of 8%. Growth in the open officina, on the other hand, was only 5%.

These expenditure relate exclusively to the innovative pharmaceutical sector. Therefore, it should be my heart that it is bizarre that especially the generic sector is affected by the measures currently in place. With potential price drops to more than 10% on generic medicines, one cannot look beyond it. I know, structural measures are absolutely necessary, but then first for the real causes of budget problems.

The proposal to increase the percentage of the objectively cheap prescription is therefore, in my opinion, a good measure, a measure which I have repeatedly advocated before.

At the same time, I am also worried. With the first amendment of sp.a, we add a sentence in the original article 19, the current article 16. The procedure for instructing doctors to prescribe medicines cheaply threatens to be delayed by that article. The percentages of low-cost regulations now set out in the law will have to be submitted to the Council of Ministers as a proposal for a decision. This will only be possible after the opinion of the national committee of physicians-patient funds or the national committee of dentists-patient funds, which will have an inhibitory effect on the prescription of cheaper, equivalent medicines. In order to avoid a delay, i.e. a weakening, of the procedure, it is appropriate to impose a strict timing on the new advisory procedure.

What I appreciate is that Minister Onkelinx tries to address the drug spending in hospitals. It is a bit of a scourge-feeding start, because the proposed measure will somewhat offset the hospital fee, but far away the measure will not bear, I fear. However, I think there are some possibilities to further increase the spending of hospitals, especially when it comes to medicines.

There will be other proposals, as I have stated in the committee. These are included in the General Policy Note. In addition, the program law contains a series of proposals aimed at reducing the cost of medicines, both at the expense of patients and for social security.

I easily agree that your philosophy is extremely important – you need to remain very vigilant – in particular to allow innovative medicines to be taken into account. You also mentioned medicines for orphan diseases. Our main problem in this regard is the extremely high price of both orphan disease medicines and innovative medicines.

In order to continue the correct reimbursement of these medicines, measures will need to be strengthened. We will have the opportunity to discuss this in the coming weeks.

That is why I want to make a proposal today, in particular on generic drugs in hospitals. Everyone is on the same wavelength at a certain level. Everyone thinks innovation is important. I also think so. It is also very important that we can continue to refund orphan medicines. However, it is necessary to examine where it can be redirected.

In this sense, it is sometimes shocking what doctors note in working groups. For example, when they prescribe generics to patients and the patients then go to a hospital, they often return with a branded medicine. These trends occur. In that sense, I would like to pay more attention to, where possible, an adjustment of the policy in this area.

Let us look at the average. I got numbers. In terms of units and amounts, we find that generics are currently reaching 2.7% and 1.9% respectively, which is really minimal. In that sense, I would like to consider how the prescription of generics, including in hospitals, can be encouraged.

I also know that there are specialties where one cannot do otherwise. However, the budget released can be re-invested in innovation or in orphan medicines. There are several possibilities that can be considered.

I would like to conclude with my third amendment, also concerning the funding of hospitals. Mr. Goutry has already stated that the issue is a very old one. The story has, unfortunately, been going on for years. Hospitals want more money. Everyone can read that in the newspapers. It is a question that arises repeatedly.

What I find important – I think most of my colleagues have the same opinion – is that the aforementioned causes a huge and serious problem. After all, the additional resources needed for the hospital budget are still charged or transferred to the patient through the supplements. This undermines all instruments to keep health care affordable for those concerned, such as OMNIO and the maximum invoice. Supplements are not included, so patients must pay for them themselves and without the help of the health insurance.

Several studies show that the patient already has to pay for 28% of the medical costs in hospitals, such as brake fees and supplements. We have really reached the ceiling.

The amendment, the new article 5, 1 – instead of the new article 8/1 – aims to ensure that no supplements can be charged for double and multi-person rooms. In addition, we set a clear limit for single rooms. In single rooms, the honorary salary supplements must be clearly plafoned. This applies to all doctors, regardless of whether they are conventional or not. The supplements are limited to 100% of the commitment rates.

During the discussion of the draft law containing various provisions in May, I have already submitted an amendment to better regulate the supplements. The amendment was then rejected. However, Minister Onkelinx also said at the time that it does not really mean that patients still have to pay more for an identical treatment depending on the room in which they stay. The hospital sector has been analyzing all hospital bills for a long time to develop a new supplement scheme. Minister Onkelinx then promised me to speed up the results so that work can be done on the new arrangement, which then can be fixed in a law. We are now a few months ahead and in my eyes there is still little or no result. Therefore, I am presenting an amendment to vote again today, hoping that the patient will no longer be fooled by the lack of a solid and transparent examination of how much money each hospital actually spends and needs.

At the point of supplements, we must be careful that we do not fall into a mold game. We will not support your amendment on the supplements because it is exactly the same as what we have submitted in the last six years at least twenty times, at every draft law and every possible discussion on health issues. It is just the same. This has always been rejected by you. Now we will do the same. I believe that in this way we will never be able to reach a meaningful debate.

Important, however, is that after a few months – although you show your impatience – we at least take a step forward in terms of the supplements. You know that at that time we were very far away with the law-Lenssens-Vermassen, when we still had that responsibility together. Then the text was reversed. We have tried to correct that. We must see that we do not constantly catch each other flying, nobody gets better from that. We will not approve your amendment. However, we will approve what is now capable. This is an improvement and the rest will come.

Mr. Goutry, you have always talked about the history of a very long time ago, when I was not in Parliament. You have been present in Parliament for a long time.

When it comes to supplements, however, we see certain phases. There was a phase of real underfinancing, with heated discussions. Then the government decided to temporarily introduce the supplements with the intention of finding a good solution. We have been waiting for this solution for years. In that sense, I find it fundamental that we as government and Parliament – I know that I am not part of the government, Mr. Bultinck – have clear transparency on that hospital funding. It does not mean that the patient is concerned about this today. I am glad that you agree to this.

Mr. Speaker, it was a little predictable that there would be a ping-pong game between colleague Goutry and colleague Detiège, but the essence is, of course, that hospital funding is not only more transparent, but that it is also correct. As long as the hospital funding does not provide sufficient resources to ensure proper functioning, the story of the supplements will always float up and then one will not be able to abolish them. No one is asking party for the supplements, but that guarantees for a very substantial part the funding of the hospitals. You know that too, Mrs. Detiège.

I just fix. I have already said this here today. If the patients can no longer withstand it and if they already have to pay 28% themselves, then one must also dare to make decisions. If there are insufficient numbers, then one must work on it.

Mr. Speaker, Mr. Minister, Ladies and Gentlemen, I will limit myself to a few chapters of the bill that is submitted to us today.

I would like, first of all, to address the issue of hospitals and to say that we support changes to the provisions on reference amounts. Indeed, it is important to know, in advance, the price range within which the cost of an operation is located. If this is not the case – this information was given to me by hospital managers whom I had the opportunity to meet – and if the doctor was paid, the said managers do not have the tool to correct a pay gap, for example. Furthermore, it is better to have, in advance, an idea of the costs to which one is exposed and to be able to organize in knowledge of cause. In addition, I consider that considering only significant deviations makes more sense than trying to recover a few hundred thousand euros in hospitals. This type of procedure is in no way a guide of good practices.

Mr. Speaker, following the recent exchanges, I feel that we have arrived at a time when it will be necessary to review almost completely the management and organization of hospitals, in connection with the presence of specialists in the latter or in private structures, with the hospital practitioners and the first line, with the supplements of fees requested, but also the private practices exercised in the context of hospitals. I would like to point out that this is not a practice specific to Belgium. Surgeons are currently on strike in France. They do not provide information about the operations they carry out because they refuse to participate in the payment of the equipment or infrastructure made available to them by the hospital to ensure their practices carried out on a private basis.

In my opinion, there is a lack of transparency, operating criteria, clear accounts. This is how we come to situations where private acts are carried out through investments made by hospitals. That is why I believe that this issue will need to be reviewed in depth. The work in this area is important and this law will not solve all problems.

So here comes the issue of medicines. We can only support the strengthening of the provisions aimed at increasing the consumption of generic drugs and the cheapest medicines.

It is obvious that every time, one tends to say that the measures taken are not sufficient because one would like to promote medicines more widely and above all to better control how the cost of a medication is estimated, and its refund. In addition, there is a real problem in controlling information as well as messages sent to drug care providers.

I had already said this when we discussed this project but I find that we have not gone far enough in the transmission of information about medicines that would be given by independent individuals working for the Ministry of Public Health and not for private companies.

It must be acknowledged that some actors in the industry receive information about medicines only through delegates and that these delegates are strongly present in offices and hospitals. There remains a spontaneity of the gesture linked to their historical place.

On the other hand, I would like to insist again on an amendment that we have put forward regarding the composition of the National Council of Nursing Art. My colleague Isabelle Durant will also submit it to the Senate next week.

I listened to the various speakers. They took, in a way, back the concerns I had expressed in the committee, stating that it was important that the people who represent the nurses and nurses in this National Council be the reflection of the different ways of working – I’m not talking about employment or self-employed status. Working at home with the network and partners is a very different way than working in a hospital where there is a well-established practice within a team or even working in residential houses for older people, which is even different. I had insisted in commission that the law incorporates a representation of these different categories.

During the debate in the committee, a fear arose. If each specialization was represented by two members, there would be a risk of getting too many delegates.

We amended the amendment we had submitted in the committee and today we propose that the different associations of nurses working at home, residential and hospital – both generalists and specialists – be equally represented. We propose to limit the number of representatives of this commission to twelve.

Without this, we will find ourselves with an almost hospital representation. For now, it is so. I know that you plan to soon be able to fund associations representing nurses, which will then be able to pay. At the same time, when you work from home, it is much more difficult to stop your work, to change your schedule. A step is therefore necessary; to do so, I feel that a legal incentive is indispensable, because a simple recommendation addressed to the associations to ensure that representation when they designate their representatives will not be enough.

The other amendments affect the new tasks entrusted to medical counselors. I will not extend on the subject: my colleague Gilkinet will speak on this point.

I just want to highlight one element that disturbs me in these changes of missions. This is confusion for the patient. In his control mission, a doctor-consultant alone embodies labor medicine and I consider that this aspect has not been sufficiently valued or developed. A visit to the counseling doctor primarily serves to see if one is really sick or if one can preserve his status of disability, disability, and others. Assigning him more of the counseling and verification tasks of the well-founded and/or efficiency of the care provided creates a confusion of roles. It is also known that some counseling doctors use sympathetic relationship to try to trap some sick; this is not healthy. That is why I would have preferred that one took the time to think about it, with all the partners including doctors, counseling doctors and others.

I would like to allow my colleague to continue on this subject.

Mr. Speaker, Mrs. Minister, as I said to you in a committee, if we support most of the measures provided for in this law which contain various provisions and which extend rights to social security or which bring useful technical corrections, we consider that there remain some fundamental problems in this text. Mainly, as Ms. Gerkens said, they relate to the announced reform of the role of counseling physicians and their interaction with general physicians. We think these provisions should have been subject to a special treatment, but I will return to it.

Among the novelties of the text that we examined in the Social Affairs Committee, I highlight the positive dimension of measures such as the opening of the right to reimbursement of health care to unaccompanied minors (the MENA), the extension of the reimbursement of travel costs between home and hospital, the abolition of contributions for some self-employed pensioners with incomplete careers or the improvement of the maximum access to billing for children with disabilities. We supported in committee the articles concerned as well as the multiple technical modifications made in various texts.

On the other hand, Mrs. Minister, we regret the removal by amendment deposited by the Government of Articles 5, 6 and 7 of the original bill, which provided for improvements concerning access to the maximum to be billed. It is said that you will come back to present us even better texts. I take a good note of it, even though I know that with this government – ⁇ more than with any other – one of yours is better than two you will have it. In any case, we will study your future projects in this area.

Our main questions relate to the proposed reforms regarding the status and future role of counseling physicians. You presented in a committee the financial revaluation of physicians-advisors as a response to the difficulty of finding candidates for this important position. As I said, it seems to me that you are taking the problem from the wrong end. The difficulty of finding doctors – mainly in rural or popular environments – comes from the numerus clausus and the insufficient number of doctors available on the market, if I can express myself so.

Here, on the contrary, you will aggravate the problem by digging the pay gap between counseling doctors and others, those who are active in medical houses, in youth assistance, in consultations for infants see general doctors. This is a leak forward that does not solve the problems of labor shortage in the health sectors.

However, the most fundamental thing in this matter, Madam the Minister, is that you make changes in the relationship between counseling physicians and general physicians without informing or consulting them.

From now on, if your text is adopted recently, the counseling physicians will have the role to play a role of first-line counseling for patients. They will also play a role in social and professional reintegration. We thought it was the role of the general physician to perform these counseling tasks. How, from now on, will the duties of the general physician and the doctor-consult articulate? We do not know! We will vote on the text and see how it will be received.

Representatives of general practitioners, whether the GBO or the ABSyM, have also reacted to your text, either by communication or by mail, regretting at least a lack of consultation. It is a reform that therefore begins on bad bases, since it causes misunderstanding and ⁇ tomorrow resistance from important actors in the medical world.

Wisdom might have desired, Madam Minister, that you take the time to inform, consult, adjust if necessary, or at least convince. The aspects of the proposed reform seem positive to us, such as the role of accompanying the care providers which is now assigned to the counseling physician.

Mr. Minister, I had proposed you in the committee to take a little time to conduct this consultation, to give you the opportunity to improve this text and convince you. Unfortunately, the majority did not follow us in the amendment we had submitted in this direction. The time that has passed since our discussions in the committee may have made its effect. That is why we are re-deposing our amendments aiming at the removal of Articles 27 to 31, in any case if I refer to the old version of the text, which would allow you to resume the file with the necessary retreat. If these amendments were not supported by a concerned majority of the opinion of general practitioners as leading actors in health matters, we would unfortunately be forced to abstain on this text.