Le financement des soins infirmiers à domicile en Belgique - KCE

14 Financing of Home Nursing KCE reports 122
Key points
• Home nursing is organised via nurses employed by private not-for-profit
organisations and via self-employed nurses.
• Two levels of nurses (bachelor-level (A1) and diploma-level (A2)) may perform
all clinical nursing interventions.
• Specialist nurse in diabetes and specialist nurse in wound care may perform
additional interventions such as diabetes education and visits for wound care
advice.
• Pilot projects are ongoing to introduce care assistants in home nursing. They
are allowed to perform a limited list of nursing interventions which are
delegated by a nurse and under supervision of a nurse.
• New organisational initiatives include:
- 1) Integrated Services for Home Care to organise multidisciplinary
consultation of primary care professionals and to support the elaboration of
multidisciplinary care plans;
- 2) The integration of home nursing into interdisciplinary primary care
practices;
- 3) Care pathways aiming to organise the multidisciplinary care for a patient
with chronic disease-specific pathology.
2.5 THE FINANCING OF HOME NURSING IN BELGIUM
2.5.1 Healthcare financing concepts
2.5.1.1 Typology of provider payment systems
Healthcare financing is the way in which money is allocated to the provider of care 12 by
health care payers (e.g. government, insurers, patients). Providers can be both individual
caregivers (GPs, specialists, physical therapists, home nurses…) and institutional
providers (hospitals, nursing homes, home health agencies…)
Jegers et al. (2002) 13 make a distinction between fixed and variable payment systems on
the basis of the relationship between activities and payment. A payment system is
considered as ‘fixed’ when the reimbursed amount does not change as activities
increase or decrease. A payment system is considered as ‘variable’ when variation in
activities induces changes in payment. Fixed and variable systems can be distinguished on
the micro-level as well as on the macro-level.
In a variable system on the micro-level, there is a direct link between the providers’
income and his activity. A classical example is a fee-for-service payment system in which
for every service a fee is paid. It is expected that it gives caregivers a strong incentive to
increase activity. The incentive is highly related to the marginal payment rate compared
to the marginal cost to produce an extra unit of activity.
In a fixed system on the micro-level, the provider is not remunerated for the
production of extra units. He receives a ‘lump sum’ which is determined ex-ante and
not related to his production. An example is the lump sum for palliative care in which
the payment is fixed and independent from the actual care given to this patient. It is
clear from this example that the payment system has to be considered as more fixed
(less variable) as the unit of reimbursement is on a more aggregate level on the
following continuum: per item-of-service, per diem, per case, per patient, per period 13 .
A financing system that is fixed at the macro-level, is called a closed-end system. Policymakers
(insurers, politicians) determine a ceiling of expenditures, which may not be
exceeded during a certain period (budget system). A financing system without any
budget limits either on a global level or for certain health care expenses is called an
open-end financing system.