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254 Musculoskeletal & Neurological Rehabilitation KCE Reports 57 13 CONCLUSIONS 13.1 SUMMARY OF FINDINGS AND KEY-POINTS The aim of this project is to study the current RIZIV/INAMI conventions for “locomotor rehabilitation” and to propose models for the organization and financing of musculoskeletal and neurological rehabilitation in Belgium. The methodology consists mainly of scientific literature search. However, where scientific data lack they are completed with grey literature, data obtained from RIZIV/INAMI, FOD/SPF and sickness funds, national and international expert opinion, and expert meetings and surveys. Based on an extensive literature search, a conceptual definition of musculoskeletal and neurological rehabilitation is developed within the framework of ICF (with specifications on individual and outcome, services, professionals and organization). The conceptual definition in a next phase has to be made operational. This should be done by the use of a comprehensive outcome model that structures all relevant outcome measures, and of a patient classification system which could ideally be used for resource allocation as well as clinical decision making. Five representative pathologies are selected for further study: THR, LEA, SCI, stroke and MS. As up to date there are no comprehensive epidemiological Belgian data available (due to a lack of systematic central registration of pathologies or delivered rehabilitation activities), epidemiological data for these pathologies are gathered following the above mentioned methodology. The following incidences are found: THR 160/100.000/year (of which 15% are considered to need multidisciplinary rehabilitation: 5% presenting with polypathology and 10% considered as fragile patients), LEA 12/100.000/year (about half receive a functional prosthesis), SCI 2/100.000/year, stroke 185/100.000/year (of which 15% need specialised rehabilitation services) and for MS an incidence of 4-6/100.000/year and a prevalence of 90/100.000/year (10% yearly need hospitalisation and 15% need continuous ambulatory treatment). Current Belgian clinical practice is investigated by means of a limited survey and compared to clinical pathways developed in several countries for the five selected pathologies. A great variance in rehabilitation practice is shown by the survey of nine Belgian medical rehabilitation specialists. This variance can be rejected nor confirmed by the study of the clinical pathways, as very few concrete data on the intensity and duration of rehabilitation are available in the detected pathways. A detailed description of the current organization and financing systems of musculoskeletal and neurological rehabilitaiton in Belgium shows that the organization and financing of musculoskeletal and neurological rehabilitation in Belgium lacks transparency and clinical coherence: several parallel payment systems exist but are mostly based on historical factors rather than on criteria related to patients’ rehabilitation needs and goals. One payment system is linked to hospital stay with specialised beds (Sp beds) for diagnosis and treatment of musculoskeletal (S2) and neurological disorders (S3). Other systems are linked to rehabilitation activities and concern mainly nomenclature (K, M and R) and rehabilitation agreements (also called conventions, general 9.50 and specific 7.71). These systems are mainly fee for service systems. Several combinations and cumulations (parallel as well as sequentially) of the different payment systems are possible, inducing a very heterogeneous rehabilitation landscape in Belgium. The different payment systems overlap significantly. There are no clear criteria for patient referral to the different types of rehabilitation organizations and the only characteristic on the limitative lists is the medical diagnosis. There are no criteria justifying an inpatient treatment. Patients’ rehabilitation needs and goals are not formally assessed. Sp-beds are financed on a 7/7 days basis, discouraging weekends home. Neither is there reimbursement for travel expenses for weekends home. Moreover,
KCE Reporst 57 Musculoskeletal & Neurological Rehabilitation 255 reimbursement for travel expenses is only provided for wheelchair bound patients and only for ambulatory treatment. A payment system for multidisciplinary follow up of patients with permanent functional impairments due to musculoskeletal or neurological disorders in the chronic phase, exists only for a very limited number of pathologies (such as neuromuscular disorders or cerebral palsy). The different rehabilitation organizations and Sp-beds are geographically relatively well spread, even though some corrections seem necessary. There is no systematic registration of data concerning the performed rehabilitation activities. There is no accreditation system and only very limited formal quality control. There is nomenclature for mono-disciplinary physical therapy and speech therapy, but not for other disciplines such as occupational therapy or psychotherapy. The RIZIV/INAMI expenditures for (multidisciplinary) musculoskeletal and neurological rehabilitation accounted for 0.38 % of the Healthcare budget in 2000 and 0.48 % in 2004. In absolute figures the expenditure for musculoskeletal and neurological rehabilitation grew about 50 % over a five year period, 2000-2004 (from €57.340.095 to €87.361.509). K-nomenclature and convention 9.50 changed significantly in 2004 and 2006. It is too early to estimate the impact of these changes but there is a trend towards increased expenses for multidisciplinary K-nomenclature. Price setting for each unit of payment, as well as per hour of therapy, depends on the system, is not transparent and mainly based on historical facts. All financing mechanisms can be qualified as variable and prospective, generating similar incentives: increasing the number of units of reimbursement and decreasing the intensity of care (and the cost) within the unit of payment. In addition, an incentive for selecting good risks is produced. An international study of five countries has been performed: The Netherlands, France, Germany, Sweden and the US. Most countries are struggling with the organization of this sector and are involved in the search for a clear rehabilitation concept comprising patients’ needs, organizations for the different phases in the trajectory (acute, postacute and chronic) and continuity of care. Unfortunately, no country disposes of a ready-for-use model for post-acute rehabilitation. All countries define different levels of rehabilitation: basic, specialised and highly specialised. For example, SCI rehabilitation is nearly always assigned to the most specialised level of care, because of the very specific needs and low incidence. Several options for organizational models in the post-acute rehabilitation phase are proposed but the ‘stratified rehabiliation model’ is recommended. This model contains three levels: general rehabilitation services, specific and highly specific rehabilitation services, organised in a network. The criteria used for patient assignment to the appropriate level are: complexity of rehabilitation needs and goals, and incidence and prevalence of consequences of health conditions. The implementation of this model requires a systematic assessment of patients’ rehabilitation needs in the acute phase of the disease trajectory, which has to be repeated periodically and can result in a transfer of an individual to another level within the network. For this assessment a PCS is needed, preferably based on the ICF framework. At this point such a PCS is not available yet and further (international) research is needed in order to develop such a tool. Awaiting this, several patient data and current assessment measures can be combined (e.g. medical diagnosis and comorbidities, age, contextual factors and functional scales such as FIM or Barthel Index). Also, it is mandatory to start as soon as possible with a central registration system for patient profiles and delivered rehabilitation activities in order to dispose of real data concerning the needs in Belgium. As in many other countries, a closed-end budget with a prospective financing system is preferable if we aim at keeping control over the rehabilitation budget. In an international context, most financing models try to integrate different components of financing rehabilitation into a lump sum approach as far as possible. In case a PCS is
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