Le financement des soins infirmiers à domicile en Belgique - KCE

90 Financing of Home Nursing KCE reports 122
As part of the innovation policy in health care, the so-called “buurtzorg” initiatives
(small scale community nursing initiatives) were launched in 2007. These local teams
consist of maximum 10 to 15 community nurses and carers providing generalist nursing
and care to people living in their homes. The teams provide care in a local community
(wijk) p
Financing of home nursing
As indicated in the introduction, an important distinction has to be made between what
is financed under ZvW on the one hand and AWBZ on the other. The yearly budget for
AWBZ and ZvW is defined by the government. For AWBZ, this overall budget is
allocated to the local care agencies (“zorgkantoren”) that contract care providers for
the necessary care activities.
In this recent period, the government has taken numerous cost-containment measures,
mainly aiming at increasing the “efficiency” of the sector. q The shift has been taken to
emphasize “output financing” of the providers, based on a variant of case mix
(functiegerichte bekostiging). The main financing mechanism has become contracting for
care, based on a set of indications of the patients. The contracting approach does not
take into account the qualifications of the nurses and carers as a point of reference. This
latter part is a main point of critique in the sector of care provision, as on the one hand
a lot of care and nursing is now being substituted to lower qualified personnel and on
the other hand that care and nursing is being increasingly organised in “stopwatch
model” undermining the care and nursing relationship.
General health insurance
The Dutch government introduced Diagnosis Treatment Combinations (DBC) to pay
insurers mainly for patient hospitalizations. It is a DRG inspired approach but has some
fundamental methodological differences too. One major difference is that DBC are not
based on an internationally recognised classification system, but on 24 different systems
of diagnosis classification, developed by different specialist medical associations. Another
main difference with 'classical DRG-systems' is the episode of care rather than the
encounter as a basis of the DBC-product.
Each DBC has a two-component price, one for the hospital, one for the medical
specialist (self-employed). Nursing is considered as an element of the hospital price.
The DBC gives an incentive to insurers to decrease the number of hospitalisation days.
Unlike most DRG systems, the Dutch DBC system describes the total episode of care
delivered in hospitals: so not only the inpatient care but also outpatient and day care.
Since 1 January 2010, so-called transmural or chain care-DBC's for non complex
chronic conditions (COPD, diabetes care, stroke, heart failure) are being introduced.
This functional model of transmural DBC financing tries to assess the costs of each
phase or episode related to a pathology, theoretically regardless of the particular coststructures
of the type of providers (the hospitals, the home care sector, the
rehabilitation sector,…) r .
The DBC-information offers the necessary information for the contract negotiations
between health insurers, the hospitals and self-employed professionals.
p http://www.nivel.nl/pdf/Rapport-Buurtzorg-nieuw-en-toch-vertrouwd.pdf
q http://www.nza.nl/nza/Nieuws/monitor_extramurale_awbz/
r This functional DBC is criticized as it is considered problematic to use for people with co-morbidities