The report is available in English with a French summary - KCE

More documents

Recommendations

Info

236 Musculoskeletal & Neurological Rehabilitation KCE Reports 57 If 1 and 2 do not explain the difference between aggregate costs and revenues, -which is unlikely given the almost certain overestimation of personnel costs- the explanation of the finding might be related to the reimbursement system: 3. The current reimbursement rules might insufficiently reflect the actual cost and cost structure of rehabilitation services. This would imply that -if the protocols that describe rehabilitation needs for five pathologies would on average be followed by all treatment centres in Belgium- the rehabilitation sector as a whole would work with deficits. In practice, centres will try to avoid deficits. Different mechanisms exist to reduce the difference between costs and revenues on the level of rehabilitation centres. First, potential deficits can be reduced by changing the case-mix of patients treated. Our assumptions on case-mix were based on estimates of experts on the percentages of patients in each pathology group needing multidisciplinary rehabilitation. Obviously, the difference between costs and revenues is larger for some pathologies than for others. This may induce an incentive towards treating more patients for which revenues are relatively closer to costs. Second, patients can be treated less intensively than described in the expert opinionbased rehabilitation protocols. The provision of rehabilitation services can be driven by the financing system. For instance, according to the rehabilitation protocols a SCI (tetra) patient needs 3 hours of individual rehabilitation treatment and one hour of group treatment per day during hospitalisation. In the K-nomenclature, however, only one K60 (corresponding to 2 hours of therapy) can be charged per day. Consequently, an incentive for providing only 2 hours of therapy is created by this reimbursement system, whereas 3 hours are needed according to the experts. 10.3.4.2 Revenues versus unit costs of ambulatory MS rehabilitation A second finding of our study is that for each of the ideal rehabilitation protocols revenues are lower than theoretical costs, except for ambulatory rehabilitation of MS under convention 7.71. The reason for this different result for ambulatory MS rehabilitation is related to the inherent nature of the reimbursement system under convention 7.71. For “MS ambulatory” the protocol defines a rehabilitation need of 1 hour individual treatment and 1 hour group treatment two times a week during 52 weeks. In convention 7.71 every session between 1 and 3 hours is charged at the same lump sum, meaning that 3 hours of treatment generate the same revenues as 1 hour of treatment. The costs as defined by the protocol borne by the rehabilitation centre relates to 1.25 hours of treatment only (1 hour group session with 4 patients implies that 0.25 hours are allocated to each patient in the group), while the reimbursement is the equivalent of a reimbursement for 3 hours of treatment. For the other pathologies, revenues were not higher than costs under convention 7.71. This is due to the fact that the lump sum per day for the 2 MS 7.71 centres (centre 1 an 2 in chapter 5) is higher than the lump sum in other 7.71 centres that also treat other pathologies. 10.3.4.3 Revenues for ambulatory versus hospital rehabilitation A third finding of our study is that the aggregate revenues for ambulatory care significantly exceed the aggregate revenues for post-acute rehabilitation in hospital if the rehabilitation protocols are on average followed. This is the case at least for convention 9.50 and convention 7.71, not for the K-nomenclature (note that revenues under Knomenclature are incomplete for several pathologies in the protocol). However, there is no significant difference between the costs of hospital rehabilitation and ambulatory rehabilitation if we take uncertainty about the percentage of ambulatory care covered by the 5 pathologies (60%) into account. If we focus on the absence of a significant difference between hospital and ambulatory rehabilitation costs and the presence of a significant difference for hospital and ambulatory rehabilitation revenues/expenditures, we can draw a number of conclusions related to the financing systems for rehabilitation in general. The discrepancy can again be attributed to the inherent financing rules under conventions 9.50 and 7.71. In convention 9.50 1 hour individual therapy and 1 hour of group therapy per session is
KCE Reporst 57 Musculoskeletal & Neurological Rehabilitation 237 “charged” in the current simulations at a rate for R60, which is actually the reimbursement of 2 hours of therapy. The costs, however, are calculated on the basis of 1.25 hours of therapy. Similarly, in convention 7.71 every session between 1 and 3 hours is charged at the same lump sum, meaning that 3 hours of treatment generate the same revenues as 1 hour of treatment (cf supra). As the ambulatory rehabilitation paths for stroke and MS are relatively long compared to the rehabilitation path in hospitalisation and as both pathologies are important determinants of the total revenues estimates, this weakness of the current financing system weighs relatively more heavy for ambulatory care than for hospital care. This implies that a difference is found between revenues for hospital and ambulatory rehabilitation that is not found between costs of hospital and ambulatory rehabilitation. It can be concluded that the relatively large difference between revenues of ambulatory rehabilitation and hospital rehabilitation is hence artificial and caused by the rules of the financing system. A reimbursement system that better ressembles the cost structure of rehabilitation services is necessary. This could imply, for instance, the implementation of a specific reimbursement rule for group sessions. The absence of a significant difference between hospital and ambulatory rehabilitation in the K-nomenclature is due to the limitation of reimbursement to 60 or 120 sessions depending on the pathology. Hence, the protocols are only partially covered by the reimbursement system based on the K-nomenclature. 10.3.4.4 Budget actually spent to rehabilitation versus estimated budgets Finally, the budget spent to musculoskeletal and neurological rehabilitation in 2004 is highly similar to our estimates of aggregate expenditures if all rehabilitation protocols would be followed and if convention 9.50 would apply for all pathologies eee . This does not apply to the situation where all rehabilitation activities would be financed through the K-nomenclature. The latter finding is related to the limitations imposed on the number of reimbursable sessions in the K-nomenclature. The protocols, as defined by the experts, are incompletely reimbursed under the K-nomenclature. Some sessions, although considered necessary, are not reimbursed. Convention 9.50, on the other hand, allows reimbursement of complete rehabilitation protocols, be it at a reduced tariff if certain limits are exceeded. The fact that the budget spent in 2004 ressembles the estimated expenditures in convention 9.50 if the protocols are followed, may mean that the optimal rehabilitation paths are currently on average followed, although there might also be discrepancies between pathologies that level each other out. On the other hand, one might argue that the experts defined their current practice as the ‘optimal’ practice. The method of using expert opinion has the inherent weakness that it might induce a bias. We tried to test the hypothesis that protocols are biased by comparing part of the actual staff (rehabilitation specialists and physical therapists) dedicated to treat stroke patients in two rehabilitation centres with the need (according to the protocols) for rehabilitation specialists and physical therapists to treat their reported number of stroke patients. Actually available staff varied from approximately 50% of the needed staff (according to the protocols) to 75% of the needed staff. A number of simulations were performed to investigate the budgetary impact of a number of scenarios. In Figure 10.11 protocol staff costs for treating one patient (stroke hosp or stroke amb) and costs for the Belgian population were calculated, assuming that total duration and the number of sessions were a fraction (50%, 60%, 70%, 80%, 90% and 100%) of the numbers specified in the protocol (the 100% column is equal to the protocol). Total costs for treating the entire population are now closer to the payments centres would receive according to current reimbursement mechanisms if protocols are followed (see the column “All centres' revenues according to current reimbursement mechanisms if eee Note that the expenditures for rehabilitation after THR (necessary for only 15% of all THR patients) should be added to the total expenditures estimates for convention 9.50, as this rehabilitation will have to be reimbursed in some way or another; if not by convention 9.50, it will have to be by other financing mechanisms. This will slightly increase the aggregate expenditure estimate for convention 9.50.
Page 1 and 2:
Organisation et Financement de la R
Page 3 and 4:
Organisation et financement de la r
Page 5 and 6:
KCE Reports 57B Réadaptation locom
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
KCE Reports 57 Musculoskeletal & Ne
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
KCE reports 57 Musculoskeletal & Ne
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
Page 107 and 108:
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Page 117 and 118:
Page 119 and 120:
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Page 199 and 200: KCE reports 57 Musculoskeletal & Ne
Page 249: KCE Reporst 57 Musculoskeletal & Ne
Page 253 and 254: KCE Reporst 57 Musculoskeletal & Ne
Page 275 and 276: KCE Reports 57 Musculoskeletal & Ne
Page 291: KCE Reports 57 Musculoskeletal & Ne
Page 294 and 295: Dépôt légal : D/2007/10.273/19
Page 296: 35. Etude relative aux coûts poten
show all

The report is available in English with a French summary - KCE

Create successful ePaper yourself

Delete template?

Save as template?