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256 Musculoskeletal & Neurological Rehabilitation KCE Reports 57 implemented, budgets are being allocated to homogeneous groups of patients included in a PCS, for each type of rehabilitation organization. The options for financing of the stratified rehabilitation model are the following. A FFS system (or mixed with high weight on FFS component) is proposed for the general rehabilitation services. For the specific and highly specific services a lump sum or mixed system with high weight on the lump component is recommended. At the highly specific level even an envelope payment system can be considered. In order to perform cost calculations, standard rehabilitation protocols are needed. Because of the limited evidence-based literature available on post-acute rehabilitation, seven experts were asked to propose a rehabilitation protocol for an average patient with one of the five selected pathologies. Expert opinion is also used to estimate Belgian incidence of rehabilitation needs per pathology when no other information was available. Data from three rehabilitation centres are used to estimate costs of these rehabilitation needs. Due to the limitations of this methodology, these estimates of costs and revenues 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. Aggregate revenues for ambulatory rehabilitation in Belgium are higher than for hospital rehabilitation. This relationship is not found for the costs of ambulatory rehabilitation and hospital rehabilitation. This points 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. 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). 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 K-nomenclature and convention 9.50. For some pathologies (especially during the initial phase of rehabilitation during hospitalization) more than 2 hours of treatment per day is needed according to the proposed protocols. The limited number of sessions and the limited duration of sessions in the Knomenclature is insufficient to cover the therapeutic needs of patients with very complex rehabilitation needs, such as spinal cord injury. The budget spent for 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. Anyway, all these data have to be interpreted with great caution due to methodological difficulties as a consequence of the lack of real data for Belgium on the one hand and scientific data on good clinical practice in musculoskeletal and neurological rehabilitation. Based on the epidemiological data and the standard rehabilitation protocols the number of needed services at each level is estimated. It is assumed that general rehabilitation can be provided by the departments of PM&R present in most acute hospitals. Maximum 20 to 30 specific rehabilitation services are needed and between 3 and 5 highly specific services. Of course, these different services can combine rehabilitation acitivities for different patient groups (e.g. stroke and LEA in specific services, SCI and TBI in highly specific services).
KCE Reporst 57 Musculoskeletal & Neurological Rehabilitation 257 In order to implement the different recommendations made in this report, the following steps are proposed. First of all patients with rehabilitation needs and goals should be indentified based on the conceptual definition to test the conceptual definition in clinical practice. Systematic registration of the patients’ profiles and delivered rehabilitation activities, in a central database, should be started as soon as possible in order to allow for correction of the estimations mentioned above, based on real data. Then, a classification system should be developed in order to assign an individual to the appropriate level of rehabilitation services with regard to his rehabilitation needs and goals at a certain point in the disease trajectory. The currently existing rehabilitation services should be reoriented to respectively general, specific and highly specific services. A network permitting collaboration between the services of the different levels at the level of clinical activities as well as concerning research and education should be installed. Patient referral can then be realised within this network using the PCS. Finally, the appropriate payment systems need to be developed for the different levels as described above. Quality control should be implemented. 13.2 COMPARISON WITH THE REPORT OF THE MINISTERIAL WORKING GROUP (PROF. HEILPORN): “NETWORK OF MUSCULOSKELETAL AND NEUROLOGICAL REHABILITATION” 13.2.1 Introduction On demand of Minister R. Demotte a “working group” was composed of different stakeholders and experts within the whole rehabilitation sector, under the direction of Prof. A.Heilporn. A subgroup concerning musculoskeletal and neurological rehabilitation held 16 meetings between January 2005 and November 2006. The report was published in 2007. The activities of the Ministerial group took place in parallel with the KCE project 2005-18 HSR titled “Organisation and Financing of Musculoskeletal and Neurological Rehabilitation in Belgium”. The aim of the Ministerial subgroup was to elaborate a concrete proposal for the organisation of musculoskeletal and neurological rehabilitation in Belgium, based on the recommendations as formulated in the policy note of the Minister and the report of the audit performed by Mr. Verhaevert of the budgetary commission of the RIZIV/INAMI (June 2004). The primary aim of the KCE project is to study the current RIZIV/INAMI conventions for ‘locomotor rehabilitation’. As financing and payment is very much related to organizational issues, the secondary aim of the study was to assess the organization and financing of musculoskeletal and neurological rehabilitation. 13.2.2 Methodology The methodology of the KCE project was described earlier in this report throughout the different chapters. Summarised, the different issues were primarily approached in a scientific way by means of a thorough search of the available scientific literature. In the different steps of this project, evidence found in scientific literature was maximally used. Where evidence lacked, other sources were used such as grey literature, national and international expert opinion, expert meetings and surveys. Also, an exercise in analysis of costs and expenditures and some financial simulations were performed. The Ministerial Subgroup applied a completely different methodology. The developed ideas are mainly based on expert opinion and dialogue between the different stakeholders, members of the subgroup. For scientific data concerning for example epidemiology reference is made to the KCE project.
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