Le financement des soins infirmiers à domicile en Belgique - KCE

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28 Financing of Home Nursing KCE reports 122 3 CROSS-NATIONAL COMPARISON 3.1 INTRODUCTION This section of the report aims at collecting information on how some other countries organise and finance home nursing. The scope of this chapter is to provide an overview of the organisation of home care services and in particular the financing of professional home nursing in a selection of countries representing different European Welfare State Regimes. Four Western European countries were included (France, UK, Germany, the Netherlands) representing different funding structures. Germany, France and the Netherlands have their roots in Bismarck-oriented social security systems with similarity in the organisation of home care and nursing (importance of non profit providers and services). The United Kingdom (UK) is included as representing an originally Beveridge oriented country with state financed health and social services. Data collection was based on a literature review, including grey literature such as reports from international or national institutions, and contacting local experts. 3.2 RESULTS The summary findings are reported in Table 10. For more detailed information, the complete case studies can be found in Appendix 4. 3.2.1 The financing of home nursing 3.2.1.1 Funding of home nursing organisations In England Primary Care Trusts provide primary and community services is particular geographic areas. Each PCT receives an annual budget by the Department of Health determined by the number of patients and the nursing needs of these patients. PCTs are accountable for remaining within their allotted budget and in achieving the clinical targets set out by the NHS. As long as PCTs are managing their patients and money appropriately, they have the freedom to use their budget. In the Netherlands the health insurance model is since 2006 organised with private health insurers constrained by government conditions guaranteeing social protection. The insurers are obliged to accept all applicants. A system of risk equalisation is foreseen to prevent direct or indirect risk selection. The financial means for covering the health insurance costs are (a) nominal premiums, (b) income related contributions through taxes on income (both employer and employee and some agencies providing allowances) and, (c) government contributions. The income-related contributions and the additional money of the state are paid to a “fund” (zorgverzekeringsfonds). This fund compensates health insurers for their obligations to accept all persons. In France and Germany home nursing is largely financed through a social health insurance scheme based on contributions from employers, employees and government contributions form taxes. Home nursing organisations are mainly funded on a fee-forservice basis. A medical referral is required for nursing acts. In France, the financing of the nursing home care services (SSIADs) is based on a daily fixed price per person taking into account average nursing time required. It is entirely covered by the National Health Insurance Fund (CNAM). This budget is supposed to cover all expenses of the service, the remuneration of all personnel, the operation costs (local, transport, administration of the service). Technical nursing activities are reimbursed based on a list of activities (nomenclature) setting the tariffs, Other activities such as communication, coordination or psychosocial interventions are not included. The self-employed nurses (IDEL) are financed by way of conventions between the sickness funds, the state and the nursing professional organisations. Sickness funds pay fees for services within constrained budgets. Some remuneration is also paid for travel costs (both fixed prices and relative prices linked to kilometres).
KCE Report 122 Financing of Home Nursing 29 Hospital at home (HAH) provide hospital-level care for patients with serious, acute or chronic illnesses in their own living environment. It aims to shorten, delay or avoid inpatient stays in acute, follow-up or rehabilitation wards whenever an admission into HAH is considered feasible. Since January 2004, hospital home care services are paid by “daily tariffs” calculated for 31 homogeneous service groups. The implementation is progressive for the public sector and only 25% of home care services are paid by these “case-mix adjusted daily tariffs” in 2005. All of the home care services provided by private hospitals which were not covered by global budgets are currently funded by these tariffs. In Germany home nursing is financed through two main insurance schemes: statutory health insurance and long term insurance. Health care services in the outpatient sector are mainly reimbursed according to a fee-for-service system with a fixed budget and floating (point) values. Sickness funds are obliged to collectively contract with all providers of ambulatory care. Complementary money is paid by households and social services. Within the health insurance framework there is a strict hierarchy of service entitlement, ranging from medical treatment, specialized nursing, basic nursing, and home help as a supplement to nursing. Specialized nursing (‘Behandlungspflege’) is financed when it is prescribed by the medical profession. The same care, provided by different categories of personnel, implies a different tariff. People who are (partly) incapable of ADL-activities are eligible for care and reimbursement under long term care insurance (LTCI). The long term care insurance provides a fixed amount of cash or benefits in kind. In the LTC, tariffs are defined for bundles of treatment, per activity or per hour or in points (e.g. washing is weighed 410 points, support with eating 250 points, making a meal 150 points). For each point a monetary value is negotiated and contracted. The budget is attributed according to the score on the dependency scale (‘Pflegestufe’) of the patient. If this budget is insufficient, the patient has to pay himself the additional expenditures, or he can fall back on social assistance (‘Sozialhilfe’). 3.2.1.2 Co-payments In these countries, no co-payment is charged for home nursing. Home nursing services are free of charge or are reimbursed by the patients' health insurance. 3.2.2 The organisation of home nursing 3.2.2.1 Technical nursing, post acute home nursing and long term care The UK is strongly oriented on community care. In France, the Netherlands and Germany, a clear distinction is made between acute and post acute care (rehabilitation) including often more technical and specialised home nursing and longer term care and nursing. This distinction is clearly embedded in the financing mechanisms and insurance regulations. In all countries, there is a debate on how to handle a delineation between nursing, care and support in the regulations. 3.2.2.2 Home nursing providers In France the hospital at home (HAD, hospitalisation à domicile) covers more or less complex/acute medical services which could/should be provided at a hospital but can be transferred to home with some medical co-ordination. Ambulatory nursing care provided at home (SSIAD, service et soins infirmiers à domicile) consists of less complex medical services. The SSIADs mainly take care of dependent (elderly) persons, in order to avoid or delay an hospitalization or an institutionalisation or to support the home back after an hospitalization. Many SSIADs combine nursing care with home care and home help (domestic care and meals on wheels). Home care provided by professionals are submitted to a medical prescription and are covered by the health insurance 36 . Two thirds of available places are managed by private organisations or notfor-profit organisations. More than 30% of available places are managed by public hospitals, municipalities or (medico-)social institutions. Independent registered nurses (IDEL: Infirmiers Diplômés d’Etat Libéraux) are the most important providers of home nursing in numbers. Independent nurses are individually responsible and work according to the medical prescription.
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