Le financement des soins infirmiers à domicile en Belgique - KCE

94 Financing of Home Nursing KCE reports 122
All health insurance funds are organised into the National Association of Health
Insurance Funds (GKV-Spitzenverband) that participates in negotiations on
remuneration and reimbursement framework contracts.
There are seven different types of sickness funds in the SHI-system: regional funds
(AOK), company-based sickness funds (BKK), guild funds (IKK), substitute funds,
agricultural funds (LKK), the maritime health insurance fund, and the Federal Miner’s
Insurance Institution (Bundesknappschaft).
Sickness fund membership is mandatory for employees whose gross income does not
exceed a certain level. Members and their dependents are entitled to the same benefits.
Independent of the status, the amount of contribution paid or the duration of insurance.
The Health Care Structure Act of 1993 gave members the right to choose a sickness
fund freely (from 1996) and to change between funds on a yearly basis with three
months’ notice. All general regional funds and all substitute funds were legally opened to
everyone and have to contract with all applicants. Company-based funds and the guild
funds may choose to remain closed, but if they open, they too have the obligation to
contract with all applicants. Sickness funds are free to set their own contribution rates,
but are subject to approval by the responsible state authority.
A risk structure compensation scheme (RSC) bb seeks to equalize differences in
expenditures among sickness funds (due to age, sex and disability). The Act to Reform
the Risk Structure Compensation Scheme introduced Disease Management Programs
(DMPs) as an instrument to reduce risk selection among funds. Upon accreditation, the
sickness funds run and coordinate the disease management programs, including the
contracting with providers. Four DMP were initially introduced (the first four conditions
for DMPs: diabetes mellitus type II, breast cancer, coronary heart disease, and
asthma/chronic obstructive lung disease).
In January 2009, the existing risk structure compensation scheme between sickness
funds has been expanded to include morbidity-oriented factors cc . The measure aims at
preventing risk selection, improving care for patients with chronic diseases and
equalizing starting points for competition between sickness funds. The introduction of
morbidity-oriented risk structure compensation ("morbi-RSA") entails a major
reorganisation of financial flows.
The morbi-RSA balances differences in risk-related expenditure:
• For each insured person, sickness funds theoretically receive a uniform flat
rate from the health fund. According to the risk structure of the individual
insured person, there are deductions or increases.
• The morbi-RSA comprises 80 diseases, split according to different levels of
severity in 106 hierarchical morbidity groups for classifying insured persons.
These 106 morbidity groups, together with 40 age/sex risk groups and 6
groups of people receiving invalidity benefits form the basis for calculating the
individual risk structure of each insured person. Additionally, sickness funds
receive a flat rate for participants of disease management programs.
• The morbi-RSA follows a prospective model:
o All SHI schemes are regulated through the Social Code Book (SGB)
o Technical nursing acts and competencies are at the core of the health
reimbursement approach. Medical referrals are needed to be entitled for
reimbursement for nursing activities under the health insurance (see
infra).
bb http://eurpub.oxfordjournals.org/cgi/reprint/11/2/174.pdf and
http://www.euro.who.int/document/e85472.pdf
cc http://www.hpm.org/en/Surveys/Bertelsmann_Stiftung_-_Germany/13/Morbiditybased_risk_structure_compensation.html