Le financement des soins infirmiers à domicile en Belgique - KCE

16 Financing of Home Nursing KCE reports 122
The different payment mechanisms lead to different provider behaviours. There is
strong evidence that an improper setup of the payment mechanisms can reduce the
quality of services 16 . Within its ‘World Health Report 2000’ the WHO modelled the
impact of provider payment systems 17,18 . Alternative payment systems are mainly
developed to contain costs (as reaction to fee-for-service systems). They may affect
quality problems such as preventing health problems (integration of patients’ health risk
into pricing practice, incentives for quality improvement and innovation), responsiveness
to legitimate expectations (reduction of fragmentation, patient oriented treatments),
providing services and solving health problems (availability of high class evidence based
therapy, prohibition of economically founded exclusions) (Table 4).
Table 4: Provider payment mechanisms and provider behaviours
Provider behaviour mechanisms
Payment
Prevent Response to Deliver Contain costs
mechanisms health legitimate services
problems expectations
Fee-for-service +/- +++ +++ ---
Diagnosis related
payment
+/- ++ ++ ++
Global budget ++ +/- -- +++
Capitation (with
competition)
+++ ++ -- +++
Source: WHO, 200018
Key: (+++) very positive effects; (++) some positive effects; (+/−) little or no effect; (−−) some
negative effects; (−−−) very negative effects.
2.5.2 Historical background
Financing of home nursing was initiated in 1948. Key-data in the development of
financing home nursing were 1964, 1988, 1997 and 2001.
In 1964, a first national agreement for reimbursement of eight nursing care
interventions was accepted by NIHDI: hygienic care, injection, wound care, cupping
glasses, enema, bladder irrigation and catheterization, and finally vaginal irrigation. It was
the start of the development of extensive nomenclature of nursing activities. This initial
scheme has been changed several times, mainly aiming at controlling and optimising
public expenses.
Based on the observation that costs for home nursing were rising, various measures for
controlling costs were introduced since the end of the 1980’s. In 1988, a day-limit for
reimbursement of home nursing was introduced. In 1991, the Belgian Evaluation Scale of
ADL (BESADL) and a mixed payment system for home nursing were introduced.
In 1997, it was accepted that nursing was more than a sum of individual activities. A
reimbursement scheme for nursing process and holistic nursing care was provided by
means of basic care provision. An additional reimbursement was provided for specific
technical nursing interventions such as the administration and supervision of parenteral
nutrition, intravenous or subcutaneous infusion, and administration via epidural
catheter.
Since 2001, home nursing activities were linked with the patients’ condition. One of the
first applications was higher reimbursement levels for palliative patients (essentially
limited to two months). Since 2001, there is a specific arrangement for nursing
assistance in haemodialysis and peritoneal dialysis at the patient’s home 19 . Other
examples (already mentioned) are the reimbursement of nursing interventions for
diabetic patients. In 2003, specific consults of specialist nurses in diabetes and/or wound
care were financed.
In 2009, a fee for one nursing consultation per year to develop a care plan was
introduced. The care plan should include: 1) a description of the need for nursing care,
2) a list of current nursing problems based on a theoretical nursing model or
classification and, 3) personalized objectives for the nursing care.