Le financement des soins infirmiers à domicile en Belgique - KCE

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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
KCE Report 122 Financing of Home Nursing 91 Long term care insurance The financing of AWBZ care is now gradually oriented in terms of case-mix characteristics and contract negotiations s . As from January 2010, the aim is to use the case mix approach (zorgzwaartepakketten) for budget allocations, contracting for care and nursing and documenting the case mix profiles of providers. The nursing needs are expressed as functions and classes (the higher the care needed, the higher the class). Based on this indication, the patient or client can claim care or support. This “class” is expressed as the (average) number of hours or parts of a day of care and support during a week. A class is defined for each AWBZ function. The indication office sets also the period (length) for which a patient can claim care or nursing. Functions and classes are combined in so-called “zorgzwaartepakketten” to set up the budget allocation. The 32 local public agencies (zorgkantoren t ) take the responsibility “to buy” care and nursing with local providers, and to control the quality of the nursing care. These agencies operate autonomous, but have tight links with local care insurers. Patients can also apply for personal budgets u . A PGB is an individually assigned, personal budget enabling an individual to negotiate himself with providers about the care arrangements he needs. The patient can also choose a mediator or agency to do it for him, or can make a combination of PGB and care organised through the care agencies. The PGB-budget is 25% lower compared to a professional care budget. The patient is not entitled to the unspent part of the cash benefits. Hospital displaced nursing (Ziekenhuisverplaatste zorg) An emerging issue, against the background of health care reforms is the so-called “ziekenhuisverplaatste zorg”: care nursing and treatment that is provided after early discharge of a hospital. For this early discharge tasks are being taken up by so-called “transfer-nurses”. These transfer-nurses or liaison function can be financed by the hospitals themselves or through home care organisation, but can also be taken into the process of CIZ. At this stage, it is not entirely clear on how this aspect of nursing and care has to managed financially. Since 2007, this so-called hospital displaced care ziekenhuisverplaatste zorg is regulated under the overall ZvW-regulations, as it is considered as part of the curative care. However home nurse organisations criticize this decision as the financing instrument would keep patient too long within the hospital setting, as no particular budget is foreseen for these transfer activities. A temporary solution was developed in 2009 that this type of nursing care could both be financed under ZvW and CIZ-AWBZ and that an intermediate contracting role has to be played by the zorgkantoren. The 2010 solution v urges to explicitly define the nursing activities in direct relation to cure interventions as part of hospital displaced nursing. Indication is needed by a medical specialist who indicates that (specialized) technical nursing is needed in the home care. A “specific” service will be developed by the Nza w in order to support the contracting of care. This solution allows that these nursing activities can either be provided (bought) by hospital nurses or by home care organisations. s http://www.nza.nl/dossier/Zorgzwaartebekostiging/zorgzwaartebekostiging t http://www.zn.nl/De_branche/Zorgkantoren/Werkzaamheden/index.asp u http://www.minvws.nl/dossiers/persoonsgebonden_budget_pgb/uitleg-pgb/ and http://www.pgb.cvz.nl/ v http://www.minvws.nl/kamerstukken/lz/2009/bekostiging-ziekenhuisverplaatste-zorg-met-ingang-van- 2010.asp w http://www.nza.nl/aanbieder/ziekenhuiszorg/beleidsregels/88211/
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Le financement des soins infirmiers à domicile en Belgique - KCE

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