Proposition 53K2524

Projet de loi portant des dispositions diverses en matière d'accessibilité aux soins de santé.

General information ¶

Submitted by

PS | SP the Di Rupo government

Submission date

Nov. 27, 2012

Official page

Visit

Status

Adopted

Requirement

Simple

Subjects

chronic illness health care illegal migration child health costs smoking nuclear medicine welfare public health medical institution health insurance

Voting ¶

Voted to adopt

Groen CD&V Vooruit Ecolo LE PS | SP Open Vld MR

Abstained from voting

∉ N-VA LDD VB

Party dissidents ¶

• Peter Luykx (CD&V) abstained from voting.

Contact form ¶

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Discussion ¶

Dec. 19, 2012 | Plenary session (Chamber of representatives)

Full source

by Mr. Mathias De Clercq, rapporteur, refers to his written report.

I also refer to my report and will later speak on behalf of my group.

Mr. Speaker, Mrs. Minister, dear colleagues, today we are discussing the draft law on accessibility of health care.

All members of the majority welcome this draft, although it has caused some discussion among the same majority. The bill also does not really satisfy our group, due to the many missed opportunities and uncertainties. Although I ⁇ do not want to exaggerate the discussion of the committee, I would like to emphasize a few points again.

Missed opportunities, Mrs. Minister, to make the consultation that you so often boast here play full play. You may give Medicomut the opportunity to speak about the introduction of a compulsory third-party payer and about the future of the honorary salary supplements, but ultimately you decide. This is a pro forma consultation, which under no circumstances guarantees that the healthcare providers concerned can decide with them.

There is also uncertainty. Will the honorary salary supplements in double rooms now be abolished? Not exactly when I read the text. In a day hospital this possibility still exists, only we do not know in which cases. The uncertainty for the patient is not eliminated.

The impact of your own legislation is also unclear. You have never answered my question whether the effects of the ban on honorary supplements in double and multi-person rooms in the hospitals concerned have been calculated. Moreover, you have actually said in the committee that it is not your concern; the hospitals concerned must solve it themselves. However, you do not deny that the financing of hospitals is not optimal and that therefore payments are often necessary. The doctors compensate for the negative effects of these payments on their income by charging supplements. In fact, you require the hospitals concerned to either demand more money from their doctors, or to dismantle part of their services. Of course it is not your problem, but the problem of the hospitals!

Ultimately, Mrs. the Minister, the patient will be the dupe of this, and especially the French-speaking patient, because the number of Flemish hospitals that still ask for supplements in double rooms, is negligible. It is about 90 hospitals, if I am not mistaken.

Missed opportunities and uncertainties in a number of crucial files make this bill somewhat difficult for our group. However, we will show our goodwill and take into account a number of other positive and necessary legislative changes in this draft. We will abstain from voting.

For the Socialist Group, financial access to quality healthcare is a priority.

Many steps have been taken in recent years to guarantee and strengthen this accessibility; I will cite a few: the gradual abolition of care supplements in common rooms and two beds, the establishment and gradual improvement of the mechanism of the maximum to be charged, the simplification of the Omnio status, the establishment of various flat-rate interventions for chronic diseases and, soon, the establishment of the status "chronic condition".

Despite these necessary and useful policies for many people and households, it remains that in 2012, some still find themselves in the obligation to interrupt a treatment, postpone it, or even renounce it. Also, a bill devoted – as its title suggests – to accessibility to health care can only satisfy us.

This text allows, I believe, to reconcile, whatever some say, the interest of those who, today, in the absence of sufficient financial resources, are not properly treated, with the interest of practitioners who have the mission and passion – I have no doubt of this – to treat everyone, having obviously the assurance of properly earning their lives.

The rights and freedoms of care providers are ⁇ ined in this project; in some aspects they are even reinforced.

Take the example of the implementation of the eCARMED project. This system will facilitate the work of healthcare providers who will be able, by addressing a single checkpoint, to be quickly and easily reimbursed for medical benefits granted to uninsured or uninsured persons.

I think it is essential to recall the reasons that motivated such a bill.

Indeed, it must be accepted that today, in 2012, some people who are working and do not enter the conditions giving right to the various social benefits that I have cited earlier, have a budget so tight that the least unexpected turns into drama.

Certainly, they can – and sometimes must – give up on things that some find superfluous, such as holidays or hobbies, but eventually also on first necessity needs, such as getting warm, dressing, or even eating properly. This is not acceptable!

And what about the amount of bills in all of this? The amount of hospital bills is often unpredictable and few are good surprises in this area. In addition, these accounts remain a factor of overindebtedness. Therefore, it is necessary to work for more tariff security and transparency in this area. This was what convinced me to submit, together with some of my colleagues, a bill aiming at the prohibition of supplementary fees in double room.

I am convinced, giving the assurance to everyone that by choosing a double bedroom, no extra fee can be required is a major step forward. Because, despite regulatory advances in this area, the information that people receive at the time of their hospitalization remains complex. We therefore believe that this measure will clarify the message by assuring patients, regardless of the hospital facility for which they choose and regardless of the doctor who will take care of them, that they will under no circumstances have to bear additional fees if they are hospitalized in double room, basic room in the vast majority of hospitals.

Let us also remind those who oppose the measure by arguing that patients have the choice to opt for a hospital that does not require additional fees and also have the choice to opt for conventional doctors, that this is not relevant in my opinion. Indeed, some patients do not have the choice of their hospital facility, and this is due to simple geographical reasons or lack of means of locomotion. The same applies to the choice of doctors. In some specialties, conventional doctors are so rare that taking appointments can redirect the provision of care to dates close to the Greek calendes! Let us finally admit that this measure has an obvious social vocation!

Furthermore, some have been tempted to identify this measure with a gift granted to certain mutual funds and insurance companies. Certainly, while 80% of Belgians benefit from hospitalization insurance, these insurance only very rarely cover the entire supplements which, in some cases, can reach 400% of INAMI rates. Very often, the intervention of these insurances is ceilinged and franchises are requested.

To say today that with this measure, insurance and mutual will win the jackpot seems to me quite exaggerated. Nevertheless, in order to reduce the potential risk of appetite for some insurance companies, the government will implement a control of the amounts of the premiums they demand.

Finally, according to some, this bill would ultimately oppose rich patients and poor patients, conventional care providers and non-conventional care providers, quality medicine and mediocre medicine, government and doctors. Of course, I can only falsify against such assertions.

First of all, I firmly oppose those who make a parallel between the convention status of care providers and the quality of their practice. What an insult to those who opt for convention! Furthermore, numerous pledges have been made to the actors of the National Medico-Mutualist Commission in order to preserve, or even strengthen, the weight of the National Medico-Mutualist Commission, in particular with regard to any subsequent revision of Article 152 of the Hospital Act or with regard to the implementation of the obligation of the third party paying to certain categories of vulnerable patients.

In conclusion, I am sure that this project, as well as all the actions carried out by the Minister of Health, preserves the different characteristics related to the organization and financing of our health care system. This system remains one of the best ranked in international comparisons, both in terms of satisfaction of beneficiaries and its effectiveness in terms of spending control and its fairness, ⁇ in the consumption of care.

I remain to hope that the necessary efforts made in accessibility will continue to be combined with a constant consultation with the actors of the National Medico-Mutualist Commission.

Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker. This draft covers various themes in which we, and our predecessors, have done a lot of work in the Public Health Committee over the past few years.

Initially, it is important that this draft addresses the extension of the third-party payment scheme. It is an extension to two groups, namely those who are entitled to the increased benefit and those who will receive a new status “chronically ill”. Furthermore, we consider this a very good measure. Through the expansion with these two categories, we reach more than 2 million people who are entitled to a third-party payment scheme. We are therefore convinced that this is truly an important step forward.

As I said in the committee, however, we regret, Mrs. Minister, that we have to wait until 2015. The doctors have a point, if they say that one must be technically able to handle things, when one expands the target group. I think very specifically about MyCareNet. The technology that will support this must be operational. In that sense, we hope that you can get the MyCareNet operational as soon as possible, as we also requested in the committee. We have understood that the health funds or insurance institutions can make the information available from 2014 onwards. For us, it is very important that we can apply MyCareNet as soon as possible, so that we can extend the third-party payer scheme to these two key categories. However, the extension must be done in a manner comfortable for the doctors and must be controllable by the insurance institutions so that no fraud is committed.

A second element that we have approved in this bill is the granting of the status of “chronically ill”. Mrs. Minister, I will not tell you a secret if I say that CD&V has never been a big advocate of a statute that automatically generates rights. After all, we often notice a huge difference between patients after a certain diagnosis has been made. For example, two patients with CVS may have a completely different cost pattern in their illness. They can also have a completely different profile in terms of self-saving. Certain categories may still work, while it is very difficult for other people to work. One needs much more medical care than the other. We have never been in favour of automatically generating rights for someone who has a particular disease.

Several implementing decisions still need to be prepared. You have listed three non-cumulative criteria that will need to be met. We ask you to be especially careful in this regard and to remove the concerns that we have about this problem.

The last point, with which we are most happy, is the abolition of the honorary salary supplements in the double rooms. Among others, Mr. Vercamer, present here, and I myself had submitted a proposal in that sense.

We are happy that it will eventually come to this point, at least if the design is approved by the Chamber. This eliminates absolute excesses. There were sensitive discussions on this subject in the committee. The colleagues know very well that we are still talking about fifteen to twenty hospitals, about a total of 50 million euros and about a total package of honorary supplements of more than 300 million euros. However, it is an important signal, primarily with respect to the patient. From now on, the patient will also have tariff security in the hospitals concerned, as it has by the general arrangements in many other hospitals in our country, which, by the way, have abolished the honorary supplements for double rooms for a long time.

It was often argued that only the mutualities of the abolition of honorary salary supplements would be improved and that it would not be a social measure. For us, this abolition is a social measure. After all, today — the maternity department is the exception — more than 77% of patients are still admitted in double or multi-person rooms. If we can provide those people with tariff certainty through the present draft and assure them that they will no longer have to pay honorary supplements in the future, then that is a step forward.

It is also not true that 77% of patients who end up in such rooms can benefit from extensive hospitalization insurance. Although the number of insured persons in our country is constantly increasing, we also know that a lot of people are in flat-rate systems through mutualities and through hospitalization insurance from the employers, which often only intervene flat-rate. We also see that the own share for those involved is still quite high. In that sense, it is therefore a social measure and it would be good if the draft was approved.

Our party wants to go even further in this regard. Our legislative proposal linked to this also talked about the abolition of honorary salary supplements in single rooms. I see on the ground in my region that this has been possible for a long time and that the honorary remuneration supplements in the single rooms are limited to 100% through the general arrangement of the hospitals. In addition, these are hospitals that score very well on the quality barometer, which offer a good general arrangement and where patient satisfaction is very high.

I am not blind to the situation on the ground today. I also see that if we go further and limit the honorary supplements in the single-person rooms, we will soon have to conduct the discussion about the financing of the hospitals. Several colleagues have addressed this issue in the committee. This discussion is more extensive than today, Mrs. Minister. However, many hospitals do not find it easy to get their budget around. So once again, when we begin the discussion about honorary supplements in single-person rooms, we must extend them to the general funding of hospitals.

Mrs. Minister, we are the requesting party to conduct that discussion, which, of course, is wider than the discussion about honorary remuneration supplements – it also concerns, among other things, the nomenclature –. After all, she is necessary. We must have the courage to take them in the coming months.

I would like to thank you all for supporting our proposal regarding the double rooms. Thank you for the draft you submitted. I hope that this important draft on accessibility will be adopted today.

On the occasion of this debate, I would like to address three provisions which I consider to be major: the status of “chronic affection”, the supplementary fees and the system of the paying third party.

With regard to the status of “chronic disease”, we are very pleased with this significant step forward in helping people who suffer from chronic diseases, rare diseases, orphan diseases, serious diseases that mortgage not only their own health, their own budget balance but also often that of their entire family. This does not only affect the problem of medical care; it also affects the general organization of the family, whether it is the problems of childcare or the possible abandonment of work. I am ⁇ pleased that the personal difficulties encountered by chronically ill patients are taken into account for what they are and not possibly for their social status.

A whole range of systems enable to promote the accessibility of care for people who have financial or social difficulties (the BIM and OMNIO statutes, the maximum to be billed, etc.). These mechanisms are, of course, ⁇ useful but, besides this, some people do not fall into these categories but suffer from chronic diseases that significantly affect the financial balance of their family. I am therefore pleased that the problems that these people face are taken into account for their health status above all.

In the long run, this measure will be extremely favorable and necessary. It also strengthens the health insurance insurance system, which, in my view, should not become merely a social assistance system. A social assistance system is necessary, but the health insurance system is also an insurance system. It is necessary that people who have paid contributions sometimes for very long periods can fully benefit from this insurance, when their health swings.

Before we approach the paying third party system, I would like to emphasize our commitment to the conventional system which, in my opinion, is quite essential in organizing our health care. The practical/mutual conventions have enabled in our country, since 1964, a series of extremely significant advances. This conventional system that has enabled to ensure the observance of the balances indispensable to the quality of care in our country will soon celebrate its fifty years.

I want therefore to reaffirm my attachment to this system which I consider to be threatened today, threatened because, gradually, there is a tendency to blur any difference between convention and non-convention. But from the moment when there is no more difference, I no longer see very well where a conventional system is still placed, except that it is transformed into a dirigist system that imposes, one point is all. But if it is no longer a concertation, does it still have a merit, a usefulness? It is enough to impose. It is not very complicated. Of course, I am not very supportive of such a system.

Just ask the question to a patient who will consult a conventional or unconventional specialist in the office. I think he sees the difference!

of course . I would even say that he should see it! It is important. As previously stated, conventional doctors provide quality care. So there is no problem for the patient: whether he goes to a conventional or unconventional doctor, he will have quality care.

However, I advocate the persistence of a free sector in our healthcare system. I am convinced that the free sector draws the quality of care upwards. Listen to me well! Obviously I do not say – it should not be caricaturized – that conventional doctors do not provide treatment of the same quality as unconventional doctors. Of course I never said that! On the other hand, the unconventional system allows the existence of a free sector in our healthcare system. It allows to pull the whole system up because unconventional doctors, especially in hospitals, introduce methods, especially for some surgical interventions, which force the whole sector to follow them.

It is now known that a number of well-known improvements in a large number of medical and surgical techniques have been made possible in particular by the system of supplements; without it, they would never have been born!

I repeat, the free sector is pulling the entire healthcare system upwards. Moreover, in countries where there is no free sector, the overall level of health is less good than in countries where there is one. I want to hear the contrary arguments and I am open to being proven to me the contrary, but I am convinced of that.

Furthermore, the free sector also prevents the exodus of a number of doctors outside our borders. That exodus already exists. It is known that several thousand doctors trained in Belgium work abroad, whether part-time or full-time. There is also a risk here. Sometimes people complain about the shortage of doctors. This is not due to the quota system or the numerus clausus, even though some believe it. The real reason is the difficulty of exercising and the constraints associated with the exercise of the profession that either discourage a number of practitioners or push them to work outside our borders. If one replaces a workforce, who practices the free sector and who will do so in countries where the conditions of exercise are more favourable, by doctors who are “imported” in Belgium because one can practice against them techniques that are sometimes more similar to subjection than to consideration and dignity on the professional level, I think that one is mistaken and that one takes risks in relation to the quality of our health care system in the future.

I am therefore deeply attached to the conventional system and I hope it can continue.

I come to the supplementary fees; this is obviously linked. I want to get out of a caricature. It is easy to say that fee supplements are scandalous and prevent the patient from being properly cared for but it is both excessive and abusive. I know I sometimes take a risk of wanting to get out of the cartoon, because it’s easier to say that fees supplements make the patient untreated. This is obviously false! It is now known what most of the hospital supplements requested in two-bed or single-bed rooms are for.

We know that some patients are experiencing financial difficulties; in addition, we have set up a support system for them: BIM status, OMNIO, long-term unemployed, disabled or disabled status. These are not subject to supplements; fortunately. Today, with the maximum to be charged, also applicable to chronic patients, we are further improving this accessibility. So much better.

Making believing that suppression of supplements is an eminently social measure, I really doubt. In my opinion, this is more of an ideological measure and a measure of support to the insurance sector. Indeed, one can tell what one wants, it is obvious that hospital insurance has any interest in removing supplements.

I do not say that this measure would eliminate any participation of the patient and that the hospital insurance covers all the costs of care. I know how the system works. Nevertheless, as you often say, 80% of hospitals do not practice supplements in double bedrooms. In Brussels and Liège, where some hospitals have opted for this practice, there are still establishments that do not adhere to it and that remain open to all patients. In all hospitals, conventional doctors are open to all patients, without any supplement.

That is why it is wrong to argue that this measure will radically change things. From the beginning, I would like to point out that we have accepted the removal of the two-bedroom supplements, we even negotiated it. The problem is not that we refuse this abolition, but to present it as an eminently social measure.

I refuse to be fooled, simply. I know the motives, which are not necessarily social. They may have an ideological point of view; I can accept it, because I respect the opinions of others. Some think that everyone must be on the same foot, that no difference appears between persons, that our society is entirely homogeneous, without anyone paying a different price, that everyone enjoys the same status, without difference between the individuals on earth. It is an interesting ideological program, but it is not mine!

Mr. Bacquelaine, we are in full caricature!

I say I can understand that some have an ideological view on this subject.

The second element I wanted to raise: the one who benefits today from removing supplements is not the patient. In fact, no patient who is in financial difficulties is obliged to pay supplements. This has not existed for years.

In all hospitals.

[...] is not included in the conditions for being exempt from payment of supplements.

You say that 80% of hospitals do not apply any supplementary fees.

This demonstrates that the remaining 20% could do the same from the moment the double bedroom became the norm.

It is you who say it!

I say that 80% of hospitals do not practice the supplementary fees. And those who apply them also welcome conventional doctors who do not. This means that for 90% of two-bedroom rooms, this pricing is not a bet. As for 10% of patients who pay supplementary fees, they generally benefit from hospitalization insurance. Of course, she does not take care of everything, and that is happy! Hospitalization insurance is of no interest. We must stay within certain limits. The important thing is that it does not cost too much and that the S/P ratio – to use the technical language of insurers – is favorable. In this case, this report is improved.

Mr. Bacquelaine, I wonder why you make such a hint with this story, since it concerns so few hospitals and it engages only 50 million fees in total!

In the commission, I cited the example of a birth. Take the one of my daughter, who is not in need, but whose salary is not very high. She will give birth in a clinic where her gynecologist practices, which is logical. Subsequently, it will be exposed to completely unpredictable supplements. I am therefore pleased that this measure will be abolished.

You speak in theory, but in reality patients are very often involved in a personal relationship with a doctor. When they arrive at the clinic, they must sign with their eyes closed and cannot anticipate the supplements they will be asked for.

I wonder therefore why you persist in challenging a measure that comes from an obvious, given that the double bedroom is increasingly becoming the preferred solution by patients.

First of all, I said that we assume the removal of the fee surcharges in the two-bedroom rooms, that we had negotiated this and that we accept it, under certain conditions on which I will return.

In addition, some have taken advantage of this proposal to be able to go further, in the future, by completely removing the fees supplements, including in one-bed rooms.

My point is to say that some benefit from this kind of decision and that it is not necessarily always the patients.

Let me give you a few precise examples of a hospital that I know well and that is located in my area where additional fees are still practiced. What is the purpose of these supplementary fees today? For most of them, they serve the hospital itself and hospital funding. Some of them, of course, are for doctors. What does the doctor do with that money, as a rule? He pays taxes, social contributions, non-refundable material – I will later return to the condition of revision of the nomenclature –, he pays instrumentist nurses whose benefits are not part of the fees requested for an intervention. These are real problems that are a barrier to the quality and accessibility of care. To give you an example, there are the operations of a parotid tumor. Some use a facial nerve detector because it is known that during this operation, in a certain percentage, the facial nerve is injured. If this happens, if it is true that the patient will be able to work, he will have a disability of facial paralysis, which is not very pleasant. Some doctors therefore use a facial nerve detector. This single-use detector is not refunded. In the case of use, the technical cost of the operation is higher than that contained in the INAMI nomenclature. Additional fees are used in particular to pay for the use of this device. I could give you at least twenty other examples of this type. Among these, there is the total ankle prosthesis that costs, in our country, more expensive in terms of return price than the fees requested.

This is primarily the purpose of supplementary fees. I wanted to bring these clarifications to get out of the caricature that leaves to think that the fee supplements go directly into the pocket of the doctor, who uses them at his own discretion. This statement is not entirely accurate. From time to time, things need to be brought back to their proper proportions.

I also think that the problem of fees supplements cannot be considered beyond hospital funding in general and the relations between doctors and hospitals.

I asked to consider, along with the problem of the removal of fees, that of the legal relations between doctors and hospital managers to prevent the latter from asking to collect money from the fees of doctors to manage their hospital. I read in the press yesterday that some of them would grant themselves the fourteenth and fifteenth months on the basis of salaries of 12,000 euros per month. I agree, I put a little into the caricature but, from time to time, this allows the message to pass. Currently, the legal relations between doctors and hospital managers are completely unbalanced. We need to re-balance them, that is what we have asked for. I think it is important that we can do this soon.

Similarly, it seems to me that the reform of hospital financing should be considered in order to stop confusing everything about the origin of the revenues that allow the financing of the hospital. I know that this is a hard and ambitious work but it is a major reform that must be carried out in the future, as well as the revision of the nomenclature which makes a number of acts not repayed properly, and others continue to be, while one could revision the amount of their repayment.

I would like to say one last word about supplements. The supplements have enabled the introduction, in a number of hospitals, of a mechanism of solidarity. This mechanism allows the supplements paid by those who have the ability to pay them to serve to improve the quality of care for everyone, including by paying acts and accompanying patients that are not taken into account by the nomenclature and by the social security. It seems to me that this mechanism must be preserved because it is a natural solidarity that happens in many hospitals that still practice supplements.

Regarding the paying third party, I am pleased that we have been able to reach an agreement on how to look at things. Somehow, we postpone the measure so that we can be sure that the practitioner will have the opportunity to control the assurance of the patients he treats and to make sure that we are not oriented towards a shift from consultations to home visits. I think there is a risk here.

The medical-mutualist consultation must therefore be able to examine this aspect of things and ensure that possible overconsumption is avoided. I remind you – some have considered it shocking to say this – the third-party payer carries a risk of overconsumption. My remarks are not intended to defend all doctors, because the practice of the vast majority of doctors is regular and correct, but the third party paying offers possibilities to opt for a system of overconsumption, in particular for a number of acts that, usually, are provided more or less free of charge. I think of medical advice, prescriptions of medicines, renewal of prescriptions. All this, with the third party paying, risks favouring a certain type of overconsumption. We need to be careful so that this is not the case.

Furthermore, it is essential to distinguish between conventional and unconventional doctors. We must accept the existence of a free sector and accept that a number of practitioners take responsibility for it. In doing so, they also take a risk: they have no social status, they must constitute their own pension themselves. This other system has advantages and disadvantages, but one must avoid coming to a system that would flat the differences between the conventional and the non-conventional.

Here are the comments I would like to make on this project. In conclusion, we must, at all costs, preserve our concertation system. I look forward to the three-month delay in order to ensure the tariff security of patients for the next three months.

I obviously wish the resumption of a medical-mutualist consultation on these different subjects in order to move forward in the framework of a balanced solution, which seems to me to be part of the prerequisites for a quality medicine in our country.

Uncertainty, that is the feeling that still prevails in many families, uncertainty about purchasing power, retirement, work and the future. Security is what citizens today demand and need more than ever, including in the field of health. Everyone has the right to quality health care. Therefore, there must be certainty that patients can pay their medical care bills with associated transparency, so that they know where they are financially.

Today’s plenary session adopts two proposals, which represent an important step forward in the accessibility and affordability of our health care. First, low-income patients and chronically ill people in the future will only pay the brake fee on a doctor’s visit. Secondly, the end of the hospital supplements in two- and multi-person rooms will finally also come. The two proposals reduce the inequality between patients.

Due to the expansion of the third-payer system, low-income patients and chronically ill patients only pay the brake fee on a doctor’s visit. 2.2 million Belgians would be eligible. The doctor will invoice his honorary remuneration directly to the health fund from now on. In other words, the patients no longer need to advance the full amount, thus removing a large threshold for them. Try with a low income but try to shoot a dentist bill of 80 euros. The current system has led to the fact that a whole group often delayed the doctor’s visit. Therefore, it is good that it changes.

The honorary salary supplements that doctors in some hospitals charge for admission to a two- or multi-person room will finally come to an end. The supplements create great inequalities between regions and hospitals. It is not possible that the same procedure or treatment in hospital A is much more expensive than in hospital B. Thus, by banning the honorary supplements in two- or multi-person rooms, the hospital invoice becomes a bit more transparent and cheaper for the patient.

The SP is satisfied today, but wants to go even further in the future. We would like to extend the third-payer system to all patients in the long term, so that everyone only pays the brake money to the doctor. We also want to restrict the honorary supplements in single-person rooms. That a single room is more expensive than a double room if it is not medically necessary, of course, makes sense. However, the fact that the hospital then determines that additional costs completely freely, without clear criteria, is much less logical.

Some physician syndicates and parties defend the supplements as a necessity, as an essential part of hospital financing through the system of payments where doctors give a part of their honorary remuneration to their hospital. If we question that system, we blame the doctors, according to some. That is a strange reasoning. A choice for the patient would therefore be equal to a choice against the doctor. One must then explain why one doctor charges twice as much for the same operation as his colleague, while they pay the same amount to the hospital where they work. It cannot be based on the work done, because if one doctor would solve a medical problem twice as well as the other, then only we are facing a real problem. Therefore, the only plausible explanation for the large price differences remains, the arbitrariness.

For patients who ask for a single room without medical necessity, we may, for the sake of solidarity with those who do not have the means to do so, charge a little more. However, fixed, clear tariffs are imposed, which eliminate large differences between hospitals. The room of a patient should not influence the price of the medical procedure or the treatment itself. This will ⁇ be discussed in the committee.

To conclude, colleagues, today we take an important step forward, but we remain vigilant for the concrete implementation of the bill. We will not allow abuse of the law. We want to do so in consultation with the doctors, but they must understand that personal benefits can never prevail over the interests of the patients.

Mr. Speaker, Mrs. Minister, colleagues, in general, Open Vld is satisfied with the bill, as it was adopted in the committee. This draft legislation sets important steps forward in various areas of healthcare in order to respond to developments in the sector and to promote accessibility and transparency for patients.

First of all, I will mention the abolition of honorary salary supplements in double rooms. Open Vld agrees with this, as this measure corresponds to the social reality. Only a small percentage of hospitals currently apply this additional package. Furthermore, this measure improves transparency for patients. The patient will only have to pay honorary supplements if he chooses a single room. This makes health care more accessible, a health care that should remain performing and transparent.

There are several questions to be asked about the extension of the third-payer scheme to chronically ill and socially disadvantaged persons, even though this measure should be applauded for those groups. Let there be no misunderstanding about this. For us, there is a problem when it is not taken into account whether the treating doctor is conventional or not. We believe that the imposition of the third-party payer regime can only be applied to conventional doctors. The patient will thus be encouraged to seek the doctors who respect the agreed rates. After all, the imposition of a third-payer scheme in which subsequent supplements must be paid is contradictory for Open Vld.

In the context of the third-payer scheme, I would like to further report that Open Vld is satisfied with the linking of the expansion of the third-payer system to the further expansion of the MyCareNet, in order to help avoid the heavy administrative burden for doctors.

In addition, the honorary wages are also indexed and the consultation model is ⁇ ined. These are important aspects, especially for everyone in the sector.

The conclusion of the agreement was not obvious. In particular, the issue of honorary remuneration supplements has once again made clear that a thorough reform of hospital financing is more than ever needed. It is clear that hospital funding is an old house, with weak foundations. Several rooms have been restored and re-timed several times. Even pieces have already been built. It is time for a thorough renovation.

Hospital financing is no longer transparent and is characterized by an ongoing struggle between doctors and hospital managers to distribute the limited financial resources. The nomenclature does not correspond to recent developments in medical treatments. One specialist earns too much, the other too little. Many of them turn their backs on the classical hospitals and start their own practice. In the long run, this could lead to a two-speed medicine, in which the quality of classical care decreases and only those with a certain income can afford quality care.

This is not the society we want to reach. Open Vld supports the bill, but also calls for a thorough reform of hospital financing and the nomenclature of medical benefits.

Regarding the provisions under consideration, I would like first of all to recall a progress that I find very positive. It refers to the status of “chronic affection”. Let us acknowledge that many patients, even from households, with average wages, find themselves completely caught in the throat, not in themselves because of the type of pathology or their financial resources but because of the succession of extremely large expenses that in the end, despite their average wages, put them in situations impossible. Sometimes they are even forced to postpone certain care.

To date, approximately 250,000 households benefited from the chronic disease and chronic MAF package. Tomorrow, thanks to this device and this “chronic condition” status, approximately 700,000 people will be able to benefit from it. This is a very positive progress for us. The law provides a framework, but nothing but a framework. The goal was ⁇ to have a flexible framework, but, Mrs. Minister, we expect from you a content, royal decrees. We will pay particular attention to who will be affected and the rights covered. These points are ⁇ important and will make the success of this status. We also hope that this status will be in place for 2013. I hope you can confirm it here.

The second point I would like to mention is the fee supplement for common rooms and double bedrooms. Many things have already been said and I have long expressed myself in the committee on this subject. I believe that the principle of prohibition of supplementary fees for common rooms or double bedrooms was important. This is one in ten hospitals. But let’s recognize that if some supplements were reasonable, others were much less. It happened – which was problematic for me – that some patients were surprised because they were not necessarily informed or not sufficiently informed about supplements, for example for a surgical gesture.

Mrs. Minister, I will repeat here what I have pledged in commission: I would like that three guarantees may be associated with this prohibition.

The first is that it really benefits patients and the entire population concerned. I target the 80% of Belgians who today have hospital insurance, either by choice or through their employer – which represents the majority of people.

These supplementary fees in common and two-bed rooms amount to 50 million euros. Although I have listened to my colleague from your party, Mrs. Minister, I think we should try not to break the truth. Private hospital insurance premiums have exploded in recent years, despite the regulator that has been set up via the medical index. It must be acknowledged that it is not sufficiently effective. It is unacceptable that hospital insurance premiums increase by 40 or even 50 or 60 percent over a few years.

So I would like the government to stop this explosion of premiums. To believe that tomorrow this device will allow the Belgians to no longer take hospitalization insurance is a deceit. In fact, the majority benefit from hospitalization insurance through the employer.

The second guarantee is that the measure does not harm hospitals, especially their financing, including all the careful and paramedical or non-careful hospital staff.

The good news you have announced is a re-investment of 12 million euros for hospitals, in particular for specialized doctors. Nevertheless, I fear a decrease and a greater marking of the crisis for hospitals from 2013.

Let us also acknowledge that today, the rules of the BMF are not clearly established; thus the equal treatment of hospitals seems to me little established. Therefore, it would be necessary to move forward to open up a debate and make decisions on the financing of hospitals.

Third guarantee: not to dismiss the Medical-Mutualist Commission (CMM) from its sense. The amendments are a step in the right direction. Indeed, they refer for the future to the CMM for everything concerning these issues, but a commission review will take place for the point concerning day hospitals.

A second point has led to a debate: the obligation of the third party paying social obligation. Without recalling the various issues highlighted and the problems raised, I hold that the amendment allows to answer the delicate question of significantly greater administrative burdens for doctors, following the obligation of the third party paying social.

This amendment also allows to take into account the risk of theft that represented a general removal of patients for home visits rather than for office visits; it is not home visits for patients with severe pathologies or ⁇ difficult and delicate situations, but for patients with benign pathologies and able to move.

Mrs. Minister, it is to you that I will turn to ask you to continue to take all possible initiatives in order to enable the conclusion of a medical-mutualist agreement. Otherwise, patients will pay for the broken pots. But it can only be concluded with all the parties. If this was not the case, and in particular if the Absym was not consulted, it would be a mistake.

Therefore, it is up to you to multiply the initiatives to restore dialogue and, I hope more, trust.

Mr. Speaker, although Ecolo-Groen sits in the opposition, it is certain that, when a bill contains provisions aimed at improving the quality of health care and its accessibility, our group can only support it. We have already repeatedly submitted proposals, either in the House or in the Senate, aimed at strengthening the MAF, simplifying, or even automating, the use of the OMNIO status, increasingly flat-rate interventions in reimbursements and taking into account the healthcare costs that too many people with chronic disorders have to face continuously. These are the concerns that we have supported in your bill.

Two disputed subjects mobilized some healthcare providers as well as members of this assembly. These are two-bed rooms and third-party paying, initially automatic.

With regard to these two subjects, Ecolo-Groen will support the elements found in the bill. We will support the removal of supplements requested in two bedroom rooms for several reasons. Before I talk about this, I would like to say first that the financing of hospitals will need to be revised. It is not possible to continue to work with hospitals that benefit from specialized doctors, some of whom submit technical acts and therefore receive ⁇ large reimbursements, while other specialists in these same hospitals, who sometimes provide 24-hour stays on twenty-four – I think of pediatricians – benefit from too low remuneration for these so-called intellectual benefits. There is therefore a nomenclature and differentiated reimbursement to be revised, which take into account the mobilization of these care providers within the hospital for the benefit of patients and therefore for the benefit of the community. This is the first thing, this nomenclature needs to be revised.

Somewhere, it is not normal that doctors perform acts, essentially technical acts of specialists in hospitals, which are reimbursed and therefore remunerated in a significant way and that from this remuneration, the hospital receives a sometimes significant part (sometimes up to more than 80% of the service provider's remuneration) in order to pay a series of functions and intervention tasks that are necessary within the hospital.

It is therefore necessary, in effect, to completely revise things in such a way that the different needs, the different functions are properly financed and that a more systematic recourse to the forfaitarization of remuneration, reimbursements on the basis of pathologies and services is incorporated, and no longer on the basis of the acts made. Through the excessive remuneration demanded, the role of these specialists in these hospitals is completely distorted, which is to offer specialized care to patients who need it.

Today, the system is so perverse that some doctors sell themselves to the most offering and compete with hospitals for the highest pay. This is not acceptable because the financing of the mutual tariff for these doctors is based on the community. They abuse it and destroy it.

There is a shortage of specialized doctors in general and especially in the hospital environment. This is where they must be. I “we” appeal once again because these shortages are also linked to the numerus clausus, to the INAMI quotas requested by the representatives of the doctors who, today, refuse the removal of the supplementary fees in the two-bed rooms. They didn’t want that there was so much competition between healthcare providers. Today, it is concluded that this further reinforces the overvaluation of doctors who provide in hospitals and their demands towards hospital directions. As a result, the quality of care is no longer guaranteed in some hospitals where, sometimes, we can no longer find the specialists we need. The situation is serious! The abolition of fees supplements in the rooms will only affect a number of hospitals and doctors involved in this deviation from the proper practice of health care in the hospital structure. We could therefore only support this provision.

With regard to the paying third party, the initial formulation of the articles of the law could lead to deviations. We have submitted texts in this regard. While doctors can generally claim the third party paying for the patient in financial difficulties, it is necessary that they can have access to this information. In fact, it is not normal for a patient who earns his life well to benefit from the third paying. You have modified the texts to allow this easy access, stating that this system will only come into effect when the doctor will be able to use the Ethernet system that will allow him to have easy access to this information.

Under these conditions, it is clear that we could only support this measure.

Mr. Bacquelaine, there is something that is shocking when you say that the third-party paying will bring deviations, over-facturation and sometimes over-prescription because we will be able, for the same patient, to multiply the consultations since, anyway, he does not pay. This is to assume that doctors and general doctors are liars, potential scammers. This can happen in any profession. On the other hand, when you talk about doctors and doctors specialists in hospitals and especially those who are not conventional and those who ask for supplements, there, suddenly, there is no longer an allusion to the fact that these doctors can also abuse in their practices, in the benefits, in the bills they request. I would like that when it is said that healthcare providers can abuse a system, it is in a general way, including in private hospitals by non-conventional doctors and by doctors who demand supplementary fees.

Mr. Speaker, first about the paying third, in general medicine, I said – and I specified it a quarter of an hour ago – that the vast majority of doctors practice in a totally correct and regular way. I repeat it. Two – and I said it in commission – no doctor refuses to treat a patient because he cannot pay. This does not exist except in the imagination of a few persecuted. Doctors have always been treating. They have also sworn that it is part of their ethics and their moral code. There are no doctors who refuse to treat patients because they would not have money. The third paying, it is a little theoretical, it amuses some because it may allow better control and gradually functionarize the doctors. Again, it is purely ideological but it does not bring any added value to the patient.

As for the doctors specialists in hospitals, I did not talk about this at all. I just said and I repeat it: the acts in hospitals, when there is overconsumption, are under pressure primarily from hospital directions. These are in the interest that there are as many acts as possible to ensure that by taking from the doctor’s fees, they can finance the hospitals. This is why – and there you are right – that the technique of hospital financing needs to be modified, which, for now, is prepared for confusion. Hospital financing needs to be reformed to avoid pressure from hospital managers on doctors in terms of consumption of acts and benefits within the hospital. This is very important.

Mr. Speaker, I would like to intervene before Mrs. Gerkens answers.

by Mr. Bacquelaine still makes a lot of ideology by wondering if others don’t!

I just want to communicate a figure: 26% of general physicians never make a third-party paying.

This relates to specific practices. These are homeopaths and acupunctors.

No no no no!

Yes Yes Yes!

I think it is impossible to organize health policies that meet the needs of the population without a minimum of ideology. If one wants health accessible to all citizens, a health philosophy must be introduced into its organization.

So we joined – and I saw the minister think from the head. I think there is a consensus to review the funding of hospitals. It needs to be reorganized differently. All healthcare providers must be revalued.

The place of specialized doctors is in hospitals and not in private offices! They must be in the structures where they are needed for the benefit of the community.

If I understand you right, Mrs. Gerkens, should the specialists no longer have activities outside the hospital? Is that what you are saying?

I would like that in the reflection that we are going to carry out on the organization of health care, one can ensure that the specialists are in the hospitals. I have no objection that they have private offices, provided that it is in addition to the work done in hospitals!

Today, we realize that specialized doctors are training, perform a few years in hospitals, often a clientele before opening a private office while hospitals are in the shortage of these specialists. This is unacceptable! Not only is it necessary to review the financing of hospitals, but it is also necessary, in collaboration with doctors, to review the place where the benefits should be exercised according to nearby care, specialized care and university hospitals that have other needs.

Madame Gerkens, I don’t know exactly if you know what you’re talking about. It would be worth going to see what is happening in the hospitals. You are making a caricature. The more a fire is set, the more you will all help to ⁇ a medical-mutualist agreement.

It’s not good to set fire or cast accusations: I’ve heard your PS colleague accuse the specialists of being archaic, of not “feeling” anything at the hospital to go and have fun next door. This is almost how you present things! Honestly, it makes no sense!

I would even tell you that I’ve never done anything but hospital. I therefore suggest that you respect each other’s work, avoiding cartoons that are rude and denigratory. Remember that when a doctor, wherever he is, sees a patient, it is not for fun, but because the patient is sick. The doctor who consults does not do it for pleasure. (The applause)

I respect the patient and I respect the doctor. On the other hand, it is regrettable, but we read every week or every month that the newspapers, the analyses, the studies conducted by the Christian Mutuality, by the Mutuality Solidaris and by all others that patients must wait six months to get an appointment in a hospital while the same doctor can receive them in his private office 15 days later. This is a reality that is also experienced by patients.

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Yes, this is read regularly!

Mrs. Fonck, what I wish is to be able to open this discussion. Given your reaction, this is a topic that seems to be taboo. Nevertheless, we should be able to say that in hospitals services must be provided, that specialized doctors are there to welcome patients, and that, in order to train future specialists, they must be in number, enjoy interesting and dignified working conditions, receive a proper remuneration. It is also necessary that the hospital that engages them has the means to organize its operation, staff, administrative or care to complete the burden of specialized physicians.

This will require a fundamental revision of the financing of hospitals, but also to have requirements for specialized doctors who must ensure presence and benefits within hospital structures. Then, if they wish, a private practice: in addition and not instead of.

After explaining that we will support the proposed bill, I will conclude by saying that, in the way of distributing responsibilities, we emphasize the responsibility of all service providers in the quality of the work they perform, in compliance with the constraints imposed on them, but also the responsibility of the policy towards the regulation of the supply of health care and towards the quality and care requirements required by the service providers and healthcare institutions. This was the last responsibility I wanted to emphasize.

So if I understood you well, Mrs. Gerkens, you are explaining to us that the specialists working in the hospital and preferring to go out to exercise in the private would see four times more patients if they were in the hospital environment. Sorry, but it’s not because they exercise in the hospital that they see them four times faster!

Whether in ophthalmology, dermatology or for magnetic resonance imaging, the six months of waiting are not explained by a difference between the private and the hospital. Whether you go to one or the other, you will wait as long. I see you wear glasses. It takes six months to get an appointment with an ophthalmologist. The real problem is the lack. There has been a discussion about the departure of some doctors to other countries. It is a reality. And I could even quote you the specialties that are most concerned. These questions are existential. Not for doctors, but for patients.

To encourage doctors to stay here, not only is a decent remuneration essential, but a real consideration is also. When you hear the doctors exercising in the hospital environment, you realize that they feel disqualified. That is why they prefer to leave.

I’m not judging doctors in general, but the facts are there. We received in the Public Health Commission representatives of the College of Pediatrics who had ordered a study on the situation of their peers working in hospitals, which is a real problem. These doctors are underfunded, and this study shows that we are witnessing a shortage of pediatricians in hospitals.

When I speak of responsibility, I also think of politics. The number of specialists and doctors who could access these professions was limited. This was initiated at the request of some medical lobbyists. Today, we recognize that we bite our fingers and that the number of people training in these specialties as well as in general medicine is no longer sufficient.

Therefore, it is the whole system that needs to be revised. In doing so, I overwhelmed the pure framework of the Health Minister’s project on accessibility, simply to say that if the abolition of the supplement of fees in the rooms is a sensible measure, it will be insufficient if we do not also engage in a much more comprehensive reflection and a change in the funding of hospitals as well as the contingentation of health professionals.

Socio-economic uncertainty is an important factor of health inequality. Belgium is ⁇ aware of this, which, according to the OECD, is one of the countries that invest the most for everyone’s access to quality health care.

Nevertheless, Deloitte’s 2011 study shows that it is always necessary to return work to the profession. For more than 60% of the population, monthly health bills can only be paid at the price of restrictions in the essential expenses of the household. Of those who refuse to receive treatment, 39% justify it for financial reasons.

This is why, along with the indispensable support of our professionals to maintain the excellent quality of our health care, we must take steps so that everyone, regardless of their state of fortune, can benefit from it.

The project includes three major measures. First, the recognition of the status of “chronic affection”. Inami estimates that 840,000 people in Belgium are potentially under this status. With the ageing population, this number will increase.

More than half of these people are members of a household that does not have preferential refund. It is also known that these chronic diseases are the leading cause of death in Belgium. We think especially of cardiovascular diseases, cancer, diabetes, for example. We also think of very present diseases, which require very regular care: arthrosis, fibromyalgia, sclerosis, Parkinson, etc.

Chronic patients should regularly use medical care, the general doctor, the home nurse, medication, and so on. In addition, they often have problems with insurance or employment. This category of people needs help.

Thus, the status of "chronic affection" will allow to conduct differentiated policies at the level of employment, possibly, insurance, third party paying, etc., but with very precise criteria.

Ms. Muylle said earlier that she was afraid that the door would be open to abuse. In our country, – you know it – the status of “chronic affection” is very different from that that exists, for example, in France, with very precise criteria that are controlled and evaluated. In other words, it is carried out to control the evolution of the situation of the person with a chronic condition.

So I get to the second big sector, namely the extension of the compulsory paying third. It must be admitted that our heart ultimately balances between two options. On the one hand, it is necessary that every citizen of this country knows that social security is indispensable, in particular for getting treated, that a visit to the conventioned generalist without the social security represents a cost of 23.67 euros and that a visit to the same doctor, with the social security, represents a cost ranging from 1 to 6 euros, depending on the status that one has, depending on whether or not one benefits from a DMG. It is important that everyone knows that the community intervenes to enable the most vulnerable or, in some cases, the entire population to benefit from health care at a reduced price. On the other hand, we also know – mutualities tell us and doctors who work in more disadvantaged neighborhoods or care for many chronic patients – that too many people have difficulty advancing the money that will be reimbursed to them by social security. So we decided to maintain our system while extending the third-party paying to the most vulnerable or people with a chronic condition.

That said, we are facing a huge difficulty. We were warned. We listened to the doctors. I believe a lot in concertation. And whoever believes in concertation hears what is said and tries to take into account the difficulties of one another. What did the doctors say to me? They let me know that the administrative problems they have to address are important, which is true.

That being, as I recalled in the committee, we intervened a lot, on the occasion of the latest Impulseo programs, with a participation of more than 6 000 euros in the salary of an administrative aid for a doctor, and a participation of more than 3 000 euros for those who do outsourcing with an independent secretariat. This shows that we are very attentive to administrative difficulties.

The doctors also told me that the risk was significant for not recovering the fee, if the patient is not insured. Some have given me very concrete examples in the presence of the partners of the medico-mut.

Therefore, we proposed in a public health committee to postpone the entry into force of this provision in 2015, until the MyCareNet system is operational.

Therefore, we take into account the requirements of the doctors. That is postponed until 2015 and connected to MyCarenet.

I also want to answer some: Will we really move forward in MyCareNet?

I would like to remind you first that MyCareNet is a simple computer system that will allow the provider to send electronically its certificates of care and the invoicing of its fees.

I have mutual commitments. I quote them. From 1 January 2014, all service providers will be able to check online the insuredness of their patients and will also be able to see if they have a special status (OMNIO, chronic sick, etc.). As of July 1, 2014, all general physicians will switch to electronic invoicing. They will therefore receive the payment of the invoiced certificates faster and more automatically. From 1 January 2016, the system will be extended to all healthcare providers. So I have extremely precise deadlines and I will come back regularly before you to report on the evolution of this computer system.

The third measure of which we have talked a lot about: the abolition of the fee supplements for double bedrooms and common rooms. Why is it indispensable? I told you from my bench, Mr. Bacquelaine, because the double bedroom has become the norm. When your doctor or specialist doctor sends you to a hospital, you sometimes actually find yourself in a two-bedroom where fees are requested. The percentage of admissions in this type of room remains very high: 77% for conventional admissions. This is the norm and, at the same time, in 18 classical general hospitals and in 2 psychiatric hospitals, additional fees for common rooms, double bedrooms are still required. These hospitals account for 12.6% of all beds in our hospital park. Among these 20 hospitals – some of you have said it and they are right – we also see great differences in the supplements requested. Some specialists limit themselves to 50%, others raise up to 400% of the supplement.

A mutuality has just detected among its members, she said publicly a few weeks ago, a thousand patients who had to pay 1,000 euros from their pockets for a classic double bedroom hospitalization. It is nothing! Ms. Snoy explained the situation regarding childbirth and I cited the figures in commission. The national average is 388 euros, but in some hospitals, in a double room, it is 1 368 euros. When your gynecologist sends you there, you risk having a salt bill. It is true that the efforts that have been made in recent years have reduced the overall cost of hospitalization by 14% in seven years, including by eliminating room supplements. This is a good thing, but there is still work to be done. That is why this is presented.

I tell you immediately that I am not asking you to go beyond. I know that there are some bills aimed at private chambers, but these are not my intentions. I agree that our system is of very high quality, and it is specific to Belgium, with a free sector and a conventioned sector, and I do not want to change this system. But, from the moment when two-bedroom rooms have become the norm and therefore there is no real choice for hospitalized people, I believe that it is not to distort the system but to intervene for the benefit of patients.

There has been a lot of talk about hospital insurance. Let’s be honest, and nobody has said the opposite, it’s certain that most insurance companies provide intervention ceilings, franchises, packages, restrictions and, of course, bonuses. These insurances are already framed, in particular in terms of their indexation. Just for this framework, some insurers are before the Court of Justice of the European Communities. These insurance companies increased their premiums by 7.84 per cent in 2009 and again by 6.3 per cent in 2011.

I repeat that insurance companies have been raising their premiums for years, by 7.88 % in 2009 and by another 6.3 % in 2011. This is unacceptable for me.

This is a rather perverse mechanism, which allows the free fixation of insurance prices without a true understanding of the initial formation of the calculation of the premium and retention margins, as well as an indexation system that is not respected, as it is challenged by the major insurers. Therefore, it seems to me, it is more than necessary to question the formation of insurance prices to see if there is no market dysfunction or if the indexation is not abnormal.

That’s why I asked my colleague in Economics that he can contact the Price Observatory so that he analyzes the premiums required for hospital insurance both by private insurers and mutual companies. This review will have to take into account the reduction in covered risks since the State decided to ban supplements for double rooms. On the basis of this report, I will submit proposals to the government to better frame prices in this sector and thus better protect patients.

I know that this will have financial consequences for several hospitals. I obviously do not deny this, even though they will vary from one establishment to another, in particular depending on the fees on the supplementary fees. by Mr. Bacquelaine spoke of 32% in some hospitals, but they are sometimes only 6% elsewhere. That being said, you know that we had unlocked a sum of 21 million euros in 2006 for hospitals not practicing the supplements and that we had to follow a decision of the State Council, so that this amount now benefits all institutions, conventioned or not.

Furthermore, Mr Bacquelaine, your request appears to me to be correct. In fact, I intend to continue my efforts to better frame the legal relations between doctors and managers. The balance must be found to establish a system that recognizes the essential contribution of physicians to the activity, management and quality of hospitals, but also the need for a management policy that assigns clear objectives in terms of quality. In any case, doctors must be truly respected and integrated partners to the challenges and successes of the hospital, but also to its constraints.

I will put proposals on the table to improve the legal framework between doctors and the management of hospitals.

In addition, I look forward to the next June proposals regarding the nomenclature. We have difficulties. They should not be hidden. The discussion we have just had was ⁇ a bit caricatural on some points. However, it is true that some specialties are difficult to attract to hospital practice, and this poses a real problem. Some specialties have virtually no more conventional doctors. This also poses problems in terms of accessibility. Gynecology, ophthalmology, dermatology are illustrative examples in this area. Therefore, the nomenclature needs to be reworked. It is not normal for some specialists to be considered so poorly compared to others in the hospital.

It is also for this reason that I put on the table, to unlock the debate to the medical-mut, not negligible amounts. To the 12 million euros on one side, there are 7 million reserved for conventional doctors to always make the difference between conventional doctors and non-conventional doctors. This means more than 19 million euros in support of hospital practice. Of course, we must not prevent specialized doctors who have a private practice from pursuing it but we must be able to prioritize those and those who do hospital practice with its difficulties, its tariff constraints but also its guards in certain specialties that are sometimes very heavy. In this context, the amounts are on the table of the medical-mut.

I also anticipated that, in relation to what the parliament decides, we cannot go further without prior consultation with the medical-mut. Whenever I was able to do so and listening to the partners of the medico-mut, I reinserted in the bill that the medico-mut must always be able to give an opinion or make proposals prior to the intervention of the legislator.

With regard to the medical-mut, I would like to further clarify one or the other element. I obviously believe in the medico-mut because it is both a tariff security for patients and a support for doctors, the whole of doctors and then specifics for conventional doctors such as, for example, social status.

In addition, I also heard the requests made by the general physicians, including that not to touch the telematic premium in anticipation of a revision of the system in 2014. In addition, a reminder was sent to me concerning the guards. This is a complete problem. We talked a lot about this in this parliament; we talked about the new 1733 system and the financing of advanced guards. The representative associations of doctors themselves have made proposals for alternatives in the field of guards; so much better! I have put on the table ⁇ 8 million euros to support the first line, which must be strong and the heart of a successful healthcare organization.

An agreement between doctors and medical funds is therefore necessary. It is a win-win agreement for patients, doctors and our health system.

Following the difficulties of one partner, we decided to give time to the consultation, i.e. three more months for an agreement to be reached. Doing more than that is impossible.

I confirm that there is no danger to the tariff rates. Those of 2012 continue: patients are therefore protected during these three months. Moreover, there is also no danger to the mass of indexing fees in favor of doctors: we will find the formula that will allow them to recover the three months of slide.

We are in a difficult economic situation and we have chosen to protect the most vulnerable.

Remember that the healthcare budget is very important: it is about 30 billion euros. It is the most supported sector of all social security. I am convinced that it will allow both to maintain the quality of our unique health care system, to support our professionals at the heart of this system and to enable Belgium to continue its priorities for accessibility to health care, to prevent the inhabitants of the country from taking care due to lack of financial means or depriving themselves of the essential to pay for their health costs. This is my sense of collective responsibility; for me, it is an honor to participate in this work.