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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
KCE Reporst 57 Musculoskeletal & Neurological Rehabilitation 245 The first option is a lump sum covering all components of rehabilitation (e.g. diagnostic and therapeutic activities, coordination and interdisciplinary activities, infrastructure and equipment). Especially for the highly specific services this is preferable. In case of inpatient rehabilitation this lump sum may even cover components related to hospital stay (e.g. general nursing care, hotel services, infrastructure and equipment) as is the case in other countries (chapter 8). Other options hold different financing mechanisms per component of rehabilitation services. These might be considered for the specific services. • FFS for measurable diagnostic and therapeutic activities, lump sum for coordination and interdisciplinary activities, infrastructure and equipment. This option leaves the flexibility needed until more evidence is available for identifying an effective and efficient rehabilitation programme adapted to patients’ rehabilitation needs and goals. • FFS for measurable diagnostic and therapeutic activities; fee per discharge for coordination and interdisciplinary activities and a lump sum for infrastructure and equipment. The fee per discharge creates a financial incentive to admit new patients. This mechanism supposes an accountability obligation and quality control. If the budget spent by the RIZIV/INAMI is supposed to cover all costs of rehabilitation, the budget needed is about €84 million for the specific rehabilitation services and €12 million for the highly specific services. In a budget neutral scenario, where the fixed budget is supposed to be equal to the budget spent in 2004 (€82 625 881), the budget needed is €48 million for the specific services and €7 million for the highly specific services. This is under the assumption that the levels as defined in this model are limited to the pathologies mentioned in each level and no other pathologies would resort in these levels. If the levels are expanded with other pathologies, the budgets –both the cost-covering and budget-neutral budgets- will increase. Figure 11.3 presents the budgets per pathology and per level for the different levels of the stratified rehabilitation model. For the total budgets per level, the 95% confidence interval limits are also presented. Especially for the general level, this interval is large.
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