The report is available in English with a French summary - KCE

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