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234 Musculoskeletal & Neurological Rehabilitation KCE Reports 57 Figure 10.10: Graphical presentation of the uncertainty around the point estimates of aggregate costs, revenues and RIZIV/INAMI expenditures for musculoskeletal and neurological rehabilitation in Belgium (revenues per payment system incomplete, see 10.3.3.) Million € 250,00 200,00 150,00 100,00 RIZIV budget in 2004: 82,63 50,00 0,00 Mean values and confidence intervals around cost, revenues and expenditures estimates All centres' cost according to protocol All centres' revenues in K30/K60 All centres' revenues in convention 9.50 All centres' revenues in convention 7.71 The point estimates of total costs, expenditures and revenues in Figure 10.9 (last row) show that all three reimbursement systems are insufficient to cover all theoretical costs for all rehabilitation services if the rehabilitation protocols would on average be followed. On a disease-specific level, revenues are found to be higher than costs under convention 7.71 for ambulatory rehabilitation of MS. For all other pathologies and systems, theoretical costs are systematically higher than revenues. Note that for convention 9.50 and convention 7.71 rehabilitation for some pathologies is not included in the estimates for revenues or expenditures while they are included in the estimates of costs. If these pathologies would, as in reality, be financed through another mechanism the revenues/expenditures would increase. In the new –although not yet implemented- K30/K45/K60 system, total revenues would be €696 461 and €386 923 for THR polypathology and THR fragile respectively. The impact on the total revenues for all centres across all pathologies is about €474 000. These point estimates do not take uncertainty in our estimates into account. The uncertainty is large, however, because we could not rely on data registrations for the estimation of the percentages of patients in need for multidisciplinary rehabilitation, especially not for ambulatory treatments. Figure 10.10 presents the confidence intervals around the point estimates of the aggregate costs, revenues and RIZIV/INAMI expenditures for Belgium. The intervals represent the uncertainty around the point estimates associated with the assumptions about the prevalences of ambulatory rehabilitation in all five pathologies and about the percentage of ambulatory rehabilitation services covered by these 5 pathologies. The confidence intervals are large for all values, which means that the uncertain variables in our model have an important effect on the estimates. The most important determinant for the estimates turned out to be the estimated percentage of ambulatory care covered by the five selected pathologies. In the base case analysis, this was assumed to be 60%. The higher the percentage is, the lower the total costs, revenues and expenditures will be. The second and third most important factors are the assumed percentage of patients with MS and stroke needing ambulatory
KCE Reporst 57 Musculoskeletal & Neurological Rehabilitation 235 10.3.4 Discussion rehabilitation. The higher these percentages are, the higher the total costs, revenues and expenditures will be. Without giving too much weight to the actual cost figures because these are based on (incomplete) data from a small number of centres, four major findings can be drawn from our analyses. Although estimates of costs and revenues should not be used for policy decision, the merit of the developed methodology is that it reveals certain weaknesses in the current reimbursement mechanisms for rehabilitation. In the following paragraphs, explanations for the main findings are sought. 10.3.4.1 Aggregate revenues versus aggregate costs A first finding is that, for all pathologies taken together, none of the reimbursement systems (K-nomenclature or conventions) covers the total aggregate costs (last row in Figure 10.9). Possible reasons for this finding can be related to the methodology used for calculating costs and revenues (points 1 and 2 hereunder) or to the specific features of the reimbursement systems (point 3). Methodological reasons for the difference between costs and revenues might be: 1. Costs are overestimated The cost estimates are based on the cost structure of 3 rehabilitation centres in Belgium. This is not a representative sample of the entire rehabilitation supply in Belgium. Estimates of unit costs, both for personnel and overhead, might be exagerated relative to the costs of other centres. For example, personnel costs for one hour of therapy are based on the annual wage cost of a professional therapist and an assumed number of working hours. The personnel costs presented are hence estimates of the costs in case no students or assistants would be deployed to do part of the rehabilitation treatment as defined in the expert-opinion based protocols. If students or assistants are deployed and if the number of working hours per year is underestimated, the costs will be lower than the costs presented in this chapter. The impact of overstimation of personnel costs is important, as personnel costs are about 80% of the total estimated rehabilitation costs. This applies for all pathologies. Overestimation of costs might also be due to the use of expert panels consisting of rehabilitation physicians to develop rehabilitation protocols. These experts may have overestimated the number of individual sessions and/or underestimated the number of group sessions in the rehabilitation protocols. If the number of individual sessions is overestimated or the number of group sessions underestimated, actual costs will be lower and come closer to the revenues. 2. Revenues are underestimated The amount of money paid for therapeutic services to patients hospitalised in a Sp-unit through the day price (“ligdagprijs”) is not included in the calculations of the revenues. It was impossible to include this in the estimates because no information is available on the percentage of this amount that can be attributed to the five pathologies under consideration in case the protocols would be followed. The impact of this exclusion is that the revenues in all financing systems are underestimated. It is unlikely, however, that this has a major impact on the estimates, as these amounts are spread over all patients receiving multidisciplinary rehabilitation in hospital. Another possible reason for underestimation of revenues, in particular in the K30/K60 system, is omission of the revenues generated by the first “diagnostic” evaluation. This activity can be charged in the K30/K60-system. The bias generated by this omission is likely to be small, as the costs of this act were also not included in the cost estimates for the rehabilitation centre and revenues generated by the act are small compared to the total revenues generated by the rehabilitation path. The omission of this cost item will hence have a downward effect on both cost and revenue estimates.
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