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238 Musculoskeletal & Neurological Rehabilitation KCE Reports 57 protocols are followed (per year)” according to current reimbursement mechanisms (Figure 10.9). Figure 10.11: Protocol staff costs for treating one patient (stroke hosp or stroke amb) and costs for the Belgian population per year, when duration and number of sessions in the protocol vary (Euro). Assumption: duration and sessions as percentage of protocol 50% 60% 70% 80% 90% 100% Total staff costs stroke hosp 4 722 5 667 6 611 7 556 8 500 9 445 Total staff costs stroke amb 3 791 4 549 5 307 6 065 6 823 7 581 All centres' personnel cost according to protocol (per year, for the entire population) stroke hosp 13 458 816 16 150 579 18 842 343 21 534 106 24 225 869 26 917 632 All centres' personnel cost according to protocol (per year, for the entire population) stroke amb 10 803 603 12 964 323 15 125 044 17 285 764 19 446 485 21 607 206 Figure 10.12 presents results, assuming that the actual amount of individual sessions is smaller that specified in the protocol (Baseline). Two variants are presented: one in which half of the individual sessions (according to the protocol) are replaced by group sessions and a second alternative where all individual sessions are replaced by group sessions. Note that no “group tariff” exists, so staff costs were lowered to account for the group sessions. Both staff costs for treating one patient (stroke hosp and stroke amb) as well as cost per year for treating the entire population are presented. Again, costs for the protocols come closer to revenues if part of the individual sessions are replaced by group sessions. Figure 10.12: Protocol staff costs for treating one patient (stroke hosp or stroke amb) and costs for the Belgian population per year, when the amount of individual sessions in the protocol is replaced by more group sessions (Euro). Baseline Assumption 50% Ind --> group All Ind --> group Individual sessions stroke hosp 2 1 0 Group sessions stroke hosp 1 2 3 Individual sessions stroke amb 1 0.5 0 Group sessions stroke amb 1 1.5 2 Total staff costs stroke hosp 9 445 7 086 4 728 Total staff costs stroke amb 7 581 5 973 4 365 All centres' personnel cost according to protocol (per year, for the entire population) stroke hosp 26 917 632 20 196 147 13 474 661 All centres' personnel cost according to protocol (per year, for the entire population) stroke amb 21 607 206 17 024 374 12 441 543 In the following chapter, the financing possibilities and financial consequences of the different rehabilitation models described in chapter 9 are presented.
KCE Reporst 57 Musculoskeletal & Neurological Rehabilitation 239 Key points • Because of the limited evidence-based literature available on post-acute rehabilitation, 7 experts were asked to propose a rehabilitation protocol for an average patient with one of five selected pathologies. Expert opinion was also used to estimate Belgian incidence of rehabilitation needs per pathology when no other information was available. Data from 3 rehabilitation centres were used to estimate costs of these rehabilitation needs. Due to the limitations of this methodology, estimates of costs and revenues as presented in this chapter should not be used for policy decisions. The merit of this methodology is that it reveals certain weaknesses in the current reimbursement mechanisms for rehabilitation. • For a given rehabilitation protocol for each of the five pathologies examined, theoretical costs are higher than revenues, except for ambulatory rehabilitation for MS in convention 7.71. The exception for MS can be explained by the specific reimbursement conditions of the two 7.71 centres specialized in MS (higher lump sum than other 7.71 centres and no separate tariff for sessions of less than 3 hours) and the long duration of ambulatory rehabilitation in this patient group. • Aggregate revenues for ambulatory rehabilitation in Belgium are higher than for hospital rehabilitation. This relationship was not found for the costs of ambulatory rehabilitation and hospital rehabilitation. This pointed towards an artefact in the estimates of the revenues caused by the rules of the current financing system. More specifically, the absence of a separate tariff for group sessions induces higher revenues than costs for group sessions. • Aggregate revenues for rehabilitation services in each of the reimbursement systems are insufficient to cover theoretical aggregate costs. This can be explained by methodological weaknesses of the study (overestimated costs or underestimated revenues) and/or to the fact that the current reimbursement system does not reflect the cost structure of rehabilitation services. The real difference between costs and revenues will moreover depend on the actual case-mix. • One illustration of this inadequate reflection of the cost structure in current reimbursement rules is the reimbursement of a maximum of 2 hours of treatment per day in the K-nomenclature and convention 9.50. For some pathologies (especially during the initial phase of rehabilitation, see the proposed protocols during hospitalization) more than 2 hours of treatment per day is needed. • The limited number of sessions and the limited duration of sessions in the K-nomenclature is insufficient to cover the therapeutic needs of patients with very complex rehabilitation needs, such as spinal cord injury. • The budget spent to musculoskeletal and neurological rehabilitation in 2004 highly resembles the estimates for aggregate expenditures if all rehabilitation protocols would be followed and if all activities would be reimbursed through convention 9.50. On the one hand, this may mean that the optimal rehabilitation paths are currently followed on average, although there might also be discrepancies between pathologies that level each other out. On the other hand, this may mean that the protocols are based on current practices rather than on rehabilitation needs.
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