Le financement des soins infirmiers à domicile en Belgique - KCE

108 Financing of Home Nursing KCE reports 122
Topic 6: Critique on capitation
Some stakeholders expressed their aversion for capitation payments without outcome
measurement, as currently used for medical houses. They expected that the capitation
would lead to patient selection and quick referral to hospital or institution for old
persons.
Topic 7: Critique on lump sum financing
The main critique on the current lump sum financing of nursing care is the lack of
transparency. Especially the fact that only minimal criteria are used for registration of
‘pseudocodes’, is questioned. Because registration of ‘pseudocodes’ is often lacking, it is
insufficiently known which nursing activities are performed for patients falling under the
rules of lump sum payments.
Topic 8: Out-of-pocket payments for patients
Some persons reflected on the patient’s out of pocket payments in home nursing. Two
participants from self-employed nurses mentioned that many home nurses, employeenurses
as well as self-employed nurses, did not charge for the co-payment part of the
patient. They argued that it should be mandatory to ask patients to pay the personal
contribution in order to hold them responsible, to take into account their personal
contribution for the MAB (‘maximum billing’) and to avoid abuse.
Alternatives (PAB)
One stakeholder from a large organisation of employee-nurses argued that the patient
in the role of manager of his budget for nursing care, such as the personal assistance
budget (PAB) for handicapped persons in the Flemish Community, was not considered
as a good model, because many patients would experience difficulties to describe their
need and choose appropriate nursing care and support.
THEME 2: ARGUMENTS FOR REFORMS
Topic 9: The extent of required change: radical or fundamental?
Reflecting on the reform process to implement new financing mechanisms, two
dominant opinions emerged: most stakeholders expressed that they preferred that the
good parts of the current system should be kept and that incremental changes would be
made for solving the critiques on the system. Two participants explicitly urged to adopt
more fundamental than just incremental changes to find a final and major solution for
the global critique on the complexity of the system. The latter participants agreed that
the financing system should be a mixed system, partly fee-for-service and partly lump
sum payments.
• “The financing system must change fundamentally but not radically. The
system must stay as a mixed system but the instruments used for determining
the financing, the keys for entrance into the system must change” (participant
10; session 1).
Stakeholders pleading for incremental changes argued that the current system, which is
a mixed system, has merits.
• “Let’s not throw everything overboard, let’s keep the good things” ... “We
should act cautiously if we want to implement invasive changes”. (participant
3; session 1)
• “Let us adapt the current mixed financing system: fee-for-service and lump
sum financing”. (participant 2; session 1)
According to these stakeholders, much of the complexity of the current system is due
to subsequent adaptations and extensions to the original sound mechanism. These
stakeholders mentioned that in the past, adaptations and extensions were made in
order to meet recent requirements with regard to prevention, quality of care, new
developments, earlier hospital discharges in acute stage of recovery, task and function
differentiation, specialization, financial support for organisational matters, enhanced