Proposition 54K3189

Projet de loi relatif au financement groupé des soins hospitaliers à basse variabilité.

General information ¶

Submitted by

MR Swedish coalition

Submission date

June 22, 2018

Official page

Visit

Status

Adopted

Requirement

Simple

Subjects

health expenditure financing health policy health care social security public health medical institution

Voting ¶

Voted to adopt

CD&V Open Vld N-VA LDD MR

Voted to reject

LE PS | SP DéFI PVDA | PTB

Abstained from voting

Groen Vooruit Ecolo ∉ PP VB

Party dissidents ¶

• Olivier Maingain (MR) voted to reject.

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Discussion ¶

July 12, 2018 | Plenary session (Chamber of representatives)

Full source

The rapporteur is Mrs Dedry.

I refer to the written report.

I would like to make a few comments and explain our voting behavior.

For the principle of low variable care, you had the support of the Ecolo-Groen group. Standardizing low variable care is good for several reasons. It will increase transparency in hospital financing, it should promote multidisciplinary cooperation and it should be budget neutral. The introduction of a global prospective amount per hospital admission is therefore a first prudent step in the necessary reform of hospital financing.

I come to my critical remarks.

This is a very cautious and very modest step. Only 9% of hospitalizations will cover 54 pathologies and only 10% of hospital funding if everything goes as desired. In other countries, they continue. I think you should have shown a little more ambition and put the bar a little higher. A major criticism of this design is that you regulate funding here while we only know the main lines of the content and not the entire content. You delegate a lot to the King, including in Articles 5 and 6, where the detailed rules are set for the inclusion of the budget of the financial resources in this global prospective amount. It also includes the establishment of the list of patient groups. The argument you use is that one will be able to take into account the evolution in the medical practice, but this can also result in a minimalist, inhibitory filling.

Finally, I would like to share some concerns and concerns of the workplace.

There is still a lot of uncertainty around low-variable childbirth care and it is demanded to provide absolutely a separate code for the baby in the event of complications. A second concern is that this is a very large transformation and that there are no additional resources to support this logistically and administratively in the hospitals. The main concern is that the explanation we have currently heard is calculated on the basis of figures from 2014. However, we must first look at what the results are, at least with the figures of 2016 and hopefully of 2017. After all, there is no guarantee that one will land at a low-variable care funding in 2019, if one is based on the figures of 2014. That would be very far from reality.

For all these reasons, the Ecolo-Green group will abstain from voting.

The reform of hospital financing is indispensable – there is no doubt – for the sustainability of our system, its quality, its effectiveness and its accessibility for the benefit of all patients but also for a fair distribution of the available resources between the different hospitals and the different hospital intervenants.

For our group, this reform of hospital financing is closely linked to other important reforms, those of the hospital landscape and networks, those of the care professions and those of the nomenclature. The text submitted to us today is therefore, in our opinion, only a first small element of this large-scale reform proudly announced in your government agreement but which is hard to realize.

We do not question the difficulty and complexity of the manoeuvre. We regret, however, the lack of a comprehensive vision in this very important matter! It is therefore difficult to pronounce when you only have a small piece of the puzzle under your eyes, you will agree.

With this text, you regulate the financing of low variability care. This is the simplest part, we’ll say, since it involves taking care of treatments that differ little between patients and between hospitals. Therefore, the financing of mid- and high variability care will remain to be settled. In what term?

It is not as if there is nothing in this matter. For many years, there has been the famous system of reference amounts. This results in a reimbursement of hospitals when they exceed the national average for a series of treatments also with low variability. The refund only occurs a posteriori and therefore leads to some budgetary unpredictability for hospitals.

With the new prospective global amounts per admission you put in place, there are more refunds for hospitals who will know, from the start, what they will receive for one or another benefit. This is a small step forward as hospitals will be able to have better control of their budget.

That said, this will still be a long-term step forward as during a fairly long transitional period, hospitals will see the two systems coexist and will therefore continue, if necessary, to refund if the reference amounts are exceeded. You will understand that in terms of simplification, it is not won.

In any case, Mr. Minister, this flat funding, we have been talking about it for a long time. As such, this idea, we could quite accept it and even support it. But your text only states this principle and nothing else. All practical arrangements are systematically returned to the King. This project looks like an empty shell. Despite the many questions asked in the committee and the answers given, it continues to raise many concerns and questions for our group.

There is no specification, for example, on the groups of patients affected by these packages. Certainly, we have learned that the supports currently covered by the reference amounts will not be the same as those covered by the new prospective global amounts. Beyond that, it remains very vague. We only have very few concrete examples and no projection available.

There is also no specification on the various elements that will be included in the package or which are or could be excluded from it. Many healthcare professionals have expressed their concerns in this regard. I think of some pediatricians or clinical biologists who fear underconsumption. According to them, some supplementary examinations could be avoided in order to enter the budget set; this, obviously, at the expense of the quality of care for patients, which is ultimately mentioned very little in this text. We regret it.

In the right line of what I just said, we also have no details on the actual financial impact of this new system on hospitals and patients. You talked about stability, but in our discussions you ended up saying that in reality it avoided overconsumption in some hospitals and that it could not be considered an economy. Find out who can. But you will allow me to have doubts about the real challenge of this part of the reform.

The reform of hospital financing should aim at better functioning of the system, fairer financing of hospitals, through greater transparency. The KCE itself believed in 2015 that the readability of the system is also an aspect not to be overlooked if we want it to receive sufficient support on the ground.

As we have already said in the committee, for our group, we are really not there. Therefore, we will not support this text today.

Mrs. Minister, it has been difficult in the complex reform of hospital financing to hit nails with heads. One of the projects that has attracted your attention and on which you are presenting a bill now concerns low variable care. You deserve my personal respect and also that of our group for the long and patient work on the subject.

In 2015, when you launched your plans, we pointed out a number of possible cliffs, namely the bundled payments and the supplement problem. We realize that they have not completely helped the world out, but it is a beginning and for that you deserve at least a plum. The debate about bundled payments is ⁇ not closed. It is not easy when a bag of money is put on the table and some actors think they should get a piece of it. This can produce a lot of negative energy. At the moment, the final details have not yet been elaborated, but we look forward to the continuation.

Another problem that you want to clearly solve is that of the supplements. The issue is at the heart of our party, especially since we, as a regional party, identify significant regional differences. It is less a Flemish problem than a Brussels and Waals problem. The present draft law offers a solution to this and you deserve our appreciation and our support.

I hear a few critical voices from my colleagues, for example, that it is only about 10 % of the hospital funding. Today, however, you have opened an important door. I also hear the concern that there would be too little care, but I do not think that Belgium is a country of too little care. In many ways, Belgium is rather a country of too much concern, where the cheesecake, which has been used for years, has ⁇ not done well.

In the skin of the reform of the hospital financing there are many lice. Luckily, you have a thick skin and an elephant patience. I wish you much success in the long quest that awaits you. We will support you soon.

Mr. Speaker, Mr. Minister, the bill presented to us is a first step in the approach plan for the reform of the financing of hospitals. This includes, as already mentioned, the so-called low variability care.

The goal is that interventions that have become standard, i.e. for which there is little variation, are reimbursed, by the public authorities, in the same way everywhere in our country. The new system therefore presents a substantial difference from the current system, as it becomes prospective and no longer retrospective.

From now on, healthcare providers will know in advance the total amount of fees that will be charged and the patient will know in advance what he will have to pay. This also allows providers to adapt and get closer to the median practice of national medical care.

Such changes require a time of adaptation. The project has been the subject of a whole series of reactions, but there have also been many consultations, adaptations and maturing.

Mr. Minister, we will have to be vigilant and react if we perceive, at some point, technical or computer difficulties, but I do not doubt that this will actually be the case. It is a framework bill and therefore many decisions, which will be the subject of a consultation with the actors, will have to be taken.

The reform has several positive aspects: increasing transparency for service providers, for the hospital, but also for patients; eliminating unexplained cost differences and identifying the respective remuneration of the various service providers, as clearly requested by the medical body.

Our country is now joining policies implemented, for a number of years, in other European countries.

We will support this bill by asking you, Mrs. Minister, to be attentive to its implementation.

Mr. Speaker, Mr. Minister, as regards the reform of the financing of hospitals, in any case, in my opinion, three things had to be guaranteed: first, quality and excellence; second, transparency, security and financial stability for both hospitals and patients; third, partnership and collaborations on the front and after hospital.

Does your project guarantee quality and excellence? and no! For me, this is an original mistake, since you have decided to start from existing financing by based the calculation of the prospective total amount on median amounts. In my view, a median amount does not necessarily guarantee the quality of care. You should have proceeded in a completely different way, namely to turn to evidence-based medicine. You talk about it often, but you only apply it when it suits you!

What about transparency and financial stability and security for hospitals and patients? On transparency, and it is quite enlightening, you are drafting a law that returns everything to the King. and everything! At this point, transparency is zero.

While the reform allows to avoid some waste, no mechanism is provided in the law to guarantee that these funds remain in hospitals, even to develop other projects, - and above all and more importantly, a stable multiannual framework is guaranteed - while they have been the subject of repeated savings in recent years, the impact of which is all but negligible both on the care staff but also on the patient.

I’ve always said, in the chapter “Transparency, Financial Stability and Security,” that your formula, seen today through possible royal arrests projects or through patient lists, of which you can’t talk to us but which were sent to hospitals, seems to be a real gas factory. And we ask ourselves again how we can, in a clear and stable way, that is, with financial security for hospitals and patients, obtain sufficient guarantees. In my view, this is not the case!

Furthermore, you did no projection, no modeling, no simulation to ensure that hospitals would not be directly penalized. On the contrary, from your reform today, we are already able to translate that some hospitals – yet all affected by structural underfinancing – will find themselves in great financial difficulties and will need, for the coming years, to plan significant repayments to INAMI. Clearly, we can already see today, the major difficulties that will affect several hospitals.

The “Transparency and Financial Security/ Financial Stability” section also poses a problem, given that your project inside hospitals risks leading to large and extremely tense discussions both between the manager and the doctors and between the major specialties themselves, which is even more delicate. Indeed, while your reform should have been coordinated with the reform on the nomenclature, you have absolutely ignored it. This also applies to the reform of the Royal Decree 78.

Finally, it was, in my view, fundamental to work in a logic of partnership and collaboration on the front and after hospital. Again, it is nothing! However, I had previously proposed different paths, since we have been discussing this reform of the financing of hospitals for some time now. You had left the door open, but all this was royally left aside.

Finally, it would have been necessary to articulate this reform with that on networks, including in terms of financing, a crucial issue in the construction of networks. There is no coordination or coordination in this area.

For all these reasons, I think this is a missed opportunity. Many uncertainties remain. The choices made are absolutely unclear, at least today. We will see what will happen to the royal decrees that you will have to draw up.

Mr. Minister, the least we can say is that where I was waiting for you – on quality, excellence, transparency, security, financial stability and on pre- and post-hospitalization work – I find no such major issues in your bill. For this reason, we will vote against.

We were very much looking forward to this bill. According to the environmentalists’ vision of financing hospital care, in the organization they envisage, propose and advocate, the forfetarization of benefits for pathologies and for groups of patients is really important. It allows for transparency, objectivation, and should allow to avoid overconsumption of acts, and in particular of acts in general the most expensive or best reimbursed by the INAMI, without necessarily being more expensive than they seem, nor the most necessary acts.

This flat-rate funding, starting with groups of patients receiving low-variability care, met one of our expectations.

This is why in the committee, as well as today, we express our disappointment about the way this bill is drafted. We are also disappointed that after discussing this, we do not have access to the elements that would allow us to understand and verify the relevance of the elements included in this package. We have waited until now for this bill to succeed. Since we had waited until now, nothing stopped us from waiting another month or two, the time that the Insurance Committee has validated all the elements. You tell us that, in relation to the benefits and the different disciplines of caregivers, different elements are still in consultation. We would like, at least at the level of the Public Health Commission, to know exactly what we are saying about.

We share your goal and endorse starting with groups of patients receiving low variability care. But obviously we cannot decide what this will actually represent in the facts. We can do this even less because elements are missing. It would also have been interesting to wait for these, as well as those that are missing, in other legislative provisions, to come to present us a coherent whole.

Among these essential elements for verifying the correctness, transparency and applicability of this type of funding, we highlight the revision of the method of calculating the nomenclature and the remuneration of the healthcare provider. In your bill, only the benefits of the different stakeholders are concerned. These will, as they usually do, distribute the money from the envelope among themselves, between disciplines and between specialisations. We know that there are difficult strength relationships within hospitals. It is known that some specialties benefit from excessive remuneration while others receive too low remuneration. This will remain. The dimension of regulation and fair and equitable distribution between service providers should, in our opinion, be part of this bill. In this way, it could have worked properly.

In the same way, you continue to allow supplements that, of course, you limit to 115%, but these are also possibilities that are not necessarily justifiable or justifiable.

The same goes for patient groups. You tell us that, in order to define them, the negotiations are ongoing with the Insurance Committee and you refuse to give us a list. You were not necessarily asked to broadcast this list, but at least you could allow us to read it and explain the reasons for these 57 groups. You gave us a few examples. You did not tell us what the different identification factors on which this distribution and group identification is based meant.

You told us that it is logical, and we should know it as parliamentarians, to first pass a law before it is passed. We know it. We are not stupid! At the same time, when a law consists only of arrests, it is logical that the parliamentary asks his minister to specify what the arrests will contain in order to know what he is voting for.

There is still a lot of work to be done, especially in the organization of hospitals. This bill comes somewhat isolated as we are waiting for a bill on network reform. It would also have been good to be able to dispose of all these texts at the same time and to have a comprehensive view of the reforms in progress to see how they organize each other.

A draft law on continuity, quality, multidisciplinarity of care, this framework law related to the reform of health professions, is also expected. Also, we know that some elements are ready. There too, it would have been interesting to have the whole of these texts in order to be able to work them, reflect on them and adopt them as forming a coherent whole.

This is a first step, you say it yourself. This is a first step that, in order to benefit from our positive vote, should have been accompanied by the content of the resolutions and also other provisions so that we know exactly what we are going to vote for.

As my colleague Anne Dedry said, we really support this principle of forfaitarization. We regret that it is not possible to know exactly what the scope of these measures is and how they will fit into more comprehensive reforms. Therefore, we will abstain from voting on the proposed vote at this plenary session.

Mr. Speaker, Mrs. Minister, many actors in the health care sector have been waiting for the envelope financing for a long time. Therefore, it is good that we can start with this, in particular to counter overconsumption, to ⁇ greater transparency and efficiency and thus to release more resources to finance hospitals. That is the finality.

I must tell you that the disappointment is great. The current arrangement still shows a lot of uncertainty and we feel that few bold choices have been made. It is really unclear to what extent increasing efficiency will release more resources for better financing the operation of hospitals. We also have the impression that little is done on the role and power of doctors. That is why there is a lot of distrust about the system’s functioning.

How will the envelope funding be distributed internally? Where will the efficiency gains go? Go to the hospital or to the doctors, to be able to work better? The supplements were also not arranged. There is transparency, but absolutely not about the supplements. As mentioned earlier, there is also no list of the different treatments and their envelopes.

What I fear the most is the following.

A lot of time has been spent in the preparation of the new way of working, but in fact, too little has been invested in the introduction of the new scheme, motivating people to deal with it, clarity and transparency. I fear that, in the long run, many actors will be disgusted or very suspicious of change and of envelope financing in general. However, that is the only way we can follow, because making everything reimbursable for everyone and everywhere and keeping it affordable is an impossible task.

Mr. Speaker, I thank the members of the Committee on Public Health, also for their interventions during the committee meetings, and of course also the rapporteur, Mrs. Dedry.

It has been said many times, but I want to repeat it, this is an important step. The approach was always phasedly planned. This was also clearly explained on 28 April, when presenting the approach plan for the three houses of hospital financing. We didn’t go ice overnight. Studies were requested from the Knowledge Centre and consultations with all possible actors were held several times. We have used a good methodology. As a result, it took longer, but while we originally only wanted to finish Phase 1, two phases are now being combined. Thus we have gained time back.

Mrs. Dedry, you asked what will happen if the baby has problems. The low-variable care applies to a healthy mother who puts a healthy baby into the world. There is another difference depending on whether it occurs with or without an epidural anesthesia. Well, that baby is, if necessary, hospitalized separately; that is still possible.

You asked for additional resources. There will be a one-off injection of €7 million for the hospitals to finance their adjustments in the accounting, regarding ICT and the like.

We used the 2014 figures for the simulations. Of course, the 2016 figures are already in. That deadline is over and was not extended, unlike Tax-on-web today. The Commission can therefore rely on these figures. It was also said that there is an update every year.

Mr. Senesael, you regret the overall vision. You are often present in committees and therefore know very well that we have a clear overall vision but that involves different bills. In addition to the financing of hospitals, it is also necessary to think about the Royal Decree No. 78 as well as the nomenclature that is being revised for fees supplements in the medical-mut agreement. It is true that many royal decrees are needed, but it is also because we have phased the introduction of the law.

So what is the real challenge? For quality care, anywhere in the country, the patient must pay the same amounts. This is obvious, but it is new in our country. Yes, it will be interesting for the patient.

Mr Vercammen, thank you for your support. The fundamental change in the financing of hospitals is indeed a titanic work. The first step is to introduce low variable care. The supplements are a topic of discussion for the Medicomut, where I am aware that it will mean a lot of struggle, but the Medicomut continues to work on it.

I think the various stakeholders have responded to the concerns. I understand that concern, because we are implementing real changes to improve the system. There are always people who prefer to keep everything as it is. However, if we carry out a reform without anyone saying anything about it, then that reform is unlikely to be heavy.

Mr. Piedboeuf, the bill has positive aspects for the actors, but it is primarily patients who will benefit.

Mrs. Fonck, you asked me three questions, which you have answered yourself. Of course, I do not share your opinion.

First of all, the key to the distribution of the amount of the paying third is clear and known in advance by each pathological group. This was not the case until now, since reference amounts were known only after several years.

This will further enhance the coordination between the different doctors. In fact, it is necessary that they come into contact regularly, for the greatest benefit of the patient.

Furthermore, the invoice he will receive will be better understood. The benefits provided before and after hospitalization are not yet taken into account in the calculation of the amount. By reading the report, you could have found that additional studies on the journey of patients before and after their hospital stay still need to be carried out. That is why the bill provides for a delegation to the King, so that he can complement the regulatory framework if studies should demonstrate the need.

Mrs. Gerkens, as regards the issue of royal decrees, as chairman of the Public Health Committee, and given your parliamentary experience, you know very well that the bill must be voted first. As he still has to pass before the Insurance Committee, it would be disrespectful that I now take the royal decrees. A minister must respect such bodies.

The bundled payment includes all fees. Several simulations have been made and are known to the field actors. The calculation will be based on 2016 fees and indexation will be taken into account. As for supplements, I have already answered.

You say you will abstain. This is not very courageous. Indeed, you have always said that you were expecting the reform of financing and that a bundled payment was necessary. Now that the bill is here, you abstain. This disappoints me.

Mrs De Coninck, I have already indicated that the honorary salary supplement is currently the debate in the Medicomut. The trade union elections for doctors are, of course, oil on the fire. However, I am sure that everyone will take responsibility. If, as I have noted earlier, the honorary supplements continue to rise, then the doctors also know that they are removing the branch on which they sit.

You asked for efficiency gains. They can, I hope, be used for the benefit of the patient, for example by again placing more nursing staff with the patient. However, the profits can be used differently by the hospitals. It has been repeatedly pointed out that this is not a savings story. There is no savings amount registered.

Finally, colleagues, the best care at the same price, no matter where the patient is in our country, this is a very good step forward.

Who is asking for the word for a response?

Mr. Minister, you find that we are not courageous by not voting for a text that meets an orientation and a goal of forfaitarization. Recognize that when you read the text, you do not know what will actually happen! Everything remains to be determined through royal arrests.

The lack of courage is your lack of transparency of not waiting for, for example, the Insurance Committee to give its opinion – and you would be more comfortable presenting things to us – or of not communicating to us the criteria you submit to it, so that we better know what we are saying about.

It is also a disappointment for us not to be able to vote for your project because we do not have knowledge of all the elements.