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244 Musculoskeletal & Neurological Rehabilitation KCE Reports 57
11.2.2.1 General rehabilitation services (simple rehabilitation needs)
Because of the lower predictability of rehabilitation activities due to an expected high
case-mix variability, a lump sum payment system is less convenient for general
rehabilitation services. A lump sum payment would bear high (financial) risk on
providers which could lead to a policy of risk selection and attempts to redirect high
cost patients to other institutions. On the other hand, it could be argued that an
increase in scale (i.e. a sufficient or number of patients) reduces the variance and the
risk for the rehabilitation centres. However it is anything but clear whether Belgian
(general) rehabilitation centres have a sufficient scale in order to reduce the financial
risk from a lump sum payment adequately.
Therefore the financing mechanism for general rehabilitation services (simple
rehabilitation needs), could be fee for service, or a mixed system with relatively high
weight of the FFS component. The service is a rehabilitation activity performed by one
or more types of professionals in a mono- or (simple) multidisciplinary way.
If only one professional is involved (mono-disciplinary rehabilitation, strictu sensu no
rehabilitation (see chapter 1) since only one discipline is involved), a therapy specific fee
is provided (e.g. physical therapy, occupational therapy, psychology, speech therapy...).
If different types of professionals are involved (multidisciplinary rehabilitation) two
options are possible.
• A first option is a common fee covering different disciplines
(multidisciplinary fee). The payment is made to the team and team
members will have to bargain on the distribution.
• A second option is a system in which every therapeutic (or medical)
discipline gets a separate fee as mentioned for mono-disciplinary
rehabilitation.
If all costs of the general rehabilitation services are supposed to be covered by the
reimbursement system, the RIZIV/INAMI should keep about €49 million available for
reimbursement of the general rehabilitation services. This is the difference between the
extrapollated total costs of rehabilitation services as calculated in Figure 10.9 and the
total costs associated with the 4 pathologies classified in the specific and highly specific
level. In case of a budget neutral operation relative to 2004, about €28 million should be
reserved for this level.
11.2.2.2 Specific and highly specific rehabilitation services (complex rehabilitation needs)
Since the number of pathologies to be treated in specific and highly specific
rehabilitation services is smaller and pathologies are relatively clearly defined, a lump
sum or mixed payment system (with relatively high weight of the lump sum component)
might be easier to implement and less contestable than in the general rehabilitation
services.
Therefore, for highly specific rehabilitation services, the proposed financing mechanism
could be based on a lump sum per treatment protocol. The lump sum can be paid by
means of different units-of-payment ggg . Alternatively, a mixed system may be chosen
with a relatively higher weight for the lump sum. In this mixed system as well, the
payment is done per treatment path, which boils down to a payment per capita with a
fixed component (the lump sum) and a variable component.
As the number of centres providing highly specialised rehabilitation services will
probably be very limited, an alternative financing system might be a fixed budget per
rehabilitation centre. The amount of this so-called “envelope” can be determined by the
case-mix of the centre. Again, a good PCS is indispensable to determine the case-mix.
For the specific rehabilitation services, a mixed system with a relatively lower weight for
the lump sum is an option, as this level is characterised by a somewhat larger number of
pathologies and less complex rehabilitation needs than the highly specific level.
ggg If the unit-of-payment is the activity then it becomes a fee-for-service