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54 Musculoskeletal & Neurological Rehabilitation KCE reports 57 Key points • In literature some efforts have been described to assess the use of minimum nursing data in post-acute rehabilitation. Different American datasets, used for different settings providing post-acute rehabilitation care (acute rehabilitation hospitals, nursing homes), all include items that assess ADL, ambulation and locomotion, and neuro/emotional/behavioural status. Although the instruments do not specify all data items identically, it seems to be possible to construct a single dataset that makes it possible to compare post-acute rehabilitation needs in different settings. • In Belgium only MVG-RIM includes functional items. It could be considered to use MVG-RIM as an intermediate profiling tool of post-acute rehabilitation, using the “fingerprints”. • However, the necessary reluctance is needed before starting to use MVG- RIM: it is not a tool developed to score for therapeutic (occupational training, physical therapy, psychology,…) activities, neither to monitor or assess the effectiveness of therapy or different aspects of rehabilitation activities. Validation will be necessary. It could be an option to validate MVG- RIM with FIM or Barthel Index, or with other instruments currently tested in other countries. It should be kept in mind that MVG-RIM can only be used for inpatient registration, and not for outpatients. • The coupling of MVG-RIM with Minimal Clinical Data (MKG-RCM) and Minimal Financial Data (MFG-RFM) sets could be included in this validation exercise. But there are important methodological issues to take into account, related to the particularities of these Belgian registrations concerning the field of rehabilitation. • Congruent with the international agenda, further efforts are needed to develop a specific rehabilitation registration system, enabling to monitor the patient-profiles and rehabilitation activities in post-acute care. One should line up with international efforts and initiatives to develop validated registration instruments in line with the ICF-concept, and to integrate these with existing registration systems.
KCE reports 57 Musculoskeletal & Neurological Rehabilitation 55 5 DESCRIPTION OF THE CURRENT ORGANISATION AND FINANCING OF MUSCULOSKELETAL AND NEUROLOGICAL REHABILITATION IN BELGIUM 5.1 DESCRIPTION OF THE BELGIAN FINANCING SYSTEM FOR MUSCULOSKELETAL AND NEUROLOGICAL REHABILITATION 5.1.1 Introduction In order to understand the complex Belgian financing system, first a typology for provider payment systems is presented, which is then applied to the financing system of rehabilitation in Belgium, concerning hospital stay as well as rehabilitation activities. Then, the different payment systems in Belgium are described in detail. In the final section of this chapter a summary of the different actual payment systems, classified according to the typology model (focussing on financial incentives created by these payment mechanisms) is presented. 5.1.1.1 Typology for provider payment systems in health care 123 This section is based on (health) economic literature on the incentives created by different payment reimbursement mechanisms. Consequently, typical assumptions (and the associated terminology) from economic theory will be used. Ideally a payment scheme should incorporate the right incentives for providers (e.g. physicians and hospital management) to ensure good quality of the health care provided on the one hand and to contain overall health care costs on the other hand. Payment mechanisms should therefore seek to resolve quite distinct (and sometimes contradictory) challenges facing the players in the health care system, i.e. patients, physicians, hospitals, insurers and government. It has often been argued that it is therefore necessary to separate the financial self-interest of the physician (and other health care providers) from his role as patient advocate. Otherwise a physician’s clinical judgement about patient care and the subsequent course of treatment may not only depend on the well-being of the patient, but also on his own financial interest. Another potential conflict could arise between the micro and the macro level : what is best for an individual patient is not always best for society 124 . A review of the literature on physician payment methods and health services reimbursement schemes reveals four major payment systems : fee-for-service (FFS), capitation, salaried and fee-for-time (FFT) 125 126 . These four basic payment or reimbursement systems can also be mixed in various ways. Each of these pure methods has its own characteristics with specific consequences which will lead to a distinct type of practice setting and which will create different incentives. A FFS system will often lead to excessive consultations, interventions and prescriptions, while a capitation system could potentially lead to a selection of good risks, implying that (on average) the level of health services provided will be suboptimal. From a cost point of view, a capitation payment mechanism will create incentives to adopt a cost-conscious way to treat patients 127 . On the macro level and focussing on policy and budget, it can be argued that the lack of control and accountability in an open-ended system (especially FFS) makes planning difficult and will often lead to a chronic overrunning of the budget. It should be noted that under (risk-based) capitation financing and supply-side cost-sharing, policy makers should be concerned that the incentives resulting from these mechanisms may distort a physicians’ clinical judgement 124 . An underlying assumption of the majority of classical economic models is that the level of all outputs is determined exogenously, i.e. by the demand of the patients. This assumes
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Dépôt légal : D/2007/10.273/19
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