Le financement des soins infirmiers à domicile en Belgique - KCE

KCE Report 122 Financing of Home Nursing 27
2.5.5.3 Control procedures
The main role of the medical advisors is to control 10% of the overall prevalent patient
population under lump sum payments. However, no control is foreseen for the
increasing number of patients receiving hygienic care delivery in the fee for service
system. It could be discussed whether control of the proper use of the evaluation
instrument should be expanded to all patients receiving hygienic care (inclusive hygienic
care in the fee-for-service payment system).
An additional problem is that no criteria are available for identifying a systematic abuse
of the assessment instrument, neither is it clear which sanctions are to be foreseen and
which appeal procedures are available for nurses.
In some NIHDI reports global average numbers of visits per day are shown for the
global care delivery in the Belgian population (see higher, note CCW 2008/35 of June
2008), but systematic analyses of individual nurses care practices or home nursing
organisations are lacking, although this would be a relatively simple job for a mutuality
or NIHDI using administrative data on invoices of nursing care provision.
Key points
• Four payment systems contribute to the financing of home nursing at the
federal level:
1. A mixed system of fee-for-service payment and lump sum payment;
2. Specific costs for home nursing organisations;
3. A subsidy for the costs related to computerization;
4. Reduced social tax contributions and Social Agreements.
• A specific arrangement covers nursing assistance in haemodialysis and
peritoneal dialysis at the patient’s home.
• The fee-for-service system covers technical nursing interventions.
• The lump sum system covers nursing interventions for patients suffering from
dependency/deficiencies in the activities of daily living (ADL). Patients
dependency is assessed by scores on the Belgian Evaluation Scale for Activities
of Daily Living (BESADL).
• In the fee-for-service payment system, a doctor's prescription is required for
reimbursement of all nursing interventions (excepted for hygienic nursing
care). This is not true for nursing care delivery under the lump sum system
(excepted for technical acts that require a doctor’s prescription under the feefor-service
payment system).
• To limit supply-induced care provision in the fee-for-service system, a
maximum day-limit is fixed on the amount of level A lump sum payment.
• The qualification structure is highly differentiated for nurses. Specialized nurses
have an extended role to autonomously take care of chronic patients with
diabetes or wounds at home.
• There is a current trend to focus nurses on technical and specialized nursing
activities by delegating basic nursing tasks to care assistants.
• The financing of home providers is not based on their qualification levels.
However, specific nursing interventions are only reimbursed when they are
performed by specialized nurses.
• Regulations for nursing care delivery at home allow the third-party payer
system. Patients only pay user charges.
• The nomenclature of nursing activities seems obsolete: a lot of complex
technical home nursing activities regularly performed are not currently
included.
• The nomenclature of nursing interventions is complex and lacks integration;
the rules avoiding cumulative reimbursement lack consistency.
• Control procedures are incomplete.