Le financement des soins infirmiers à domicile en Belgique - KCE

KCE Report 122 Financing of Home Nursing 53
5.3 SUMMARY
Four main themes were most prevailing: critics on the current system, arguments for
reform, specific nursing related topics, assessment and registration instruments.
Although the main critic on the current system was that a global vision on the
organisation and financing system of home nursing was lacking, many stakeholders also
emphasized the merits of the current system. Probably, many of the detailed critics
might find their origin in this lack of global vision. A good example is the fee for the
nursing consultation/assessment that was introduced in 2009. It makes use of a fee-forservice
financing principles but from an integrated vision on home nursing it should be
seen as an integral part of regular nursing care delivery.
The absence of a dominant global vision on the financing of home nursing might also be
the reason why most stakeholders preferred a gradual/incremental change towards new
procedures for financing. Stakeholders demonstrated consensus on their preference for
a mixed system of fee-for-service and lump sum financing. With regard to chronic care
patients, it was expected that the future lump sum payments would be based on a global
case-mix index for a practice or a service of home nurses.
Although there were no propositions/statements on control procedures, optimizing
control procedures was requested by both, representatives of home nurses and
stakeholders from sickness funds.
There were only minor differences between opinions of stakeholders from selfemployed
nurses and representatives from organisations of employee-nurses. They
agreed that fees should not be different for self-employed nurses and employee-nurses.
They also agreed on the fact that different cost structures could be taken into account
by the financing system.
Recent developments in the nursing profession might require higher levels of
specialisation among home nurses, more autonomy and less dependency on GP’s
prescription on the one hand, and more delegation of nursing care delivery to care
assistants and professional carers on the other. These developments towards new
nurses’ roles and tasks were mentioned, but few propositions were made on how these
tasks should be financed in the (near) future.
With regard to registration and assessment instruments, different opinions were
mentioned. Although most stakeholders emphasized the importance and urgent
implementation of a new instrument, there was no agreement on the objectives of its
use: control of care delivery, case-mix determination and financing, quality indicators,
care planning, ... The administrative burden of an instrument that would require a lot of
data collection, was another source for disagreement between stakeholders: some
considered that such a data collection and information gathering was necessary and
feasible, others pleaded for a simple instrument than the existing instruments. Some
stakeholders even suggested to develop a new instrument, specific for home nursing in
Belgium.
Analysis and comparison of the written scores, comments and arguments revealed no
major differences with the opinions that stakeholders expressed in the discussions.
The stakeholder discussion revealed on the one hand a demand for fundamental change
of the evaluation/assessment instrument, on the other hand a demand for adaptations
on (sub)parts of the complex financing system which seem not to function adequately
rather than a revolutionary reform of the current Belgian model. Aspects/parts of the
financing system which will need adaptations are: control and sanctions, task
differentiation, case-mix financing, integrating ‘new’ nursing interventions, coordination,
continuity of care, pay for quality, ...