Le financement des soins infirmiers à domicile en Belgique - KCE

KCE Report 122 Financing of Home Nursing 55
6 OVERALL DISCUSSION
6.1 SCOPE AND LIMITATIONS OF THE STUDY
The scope of this study is limited to homecare nursing as it is currently financed at the
Belgian federal level through the NIHDI (RIZIV/INAMI). The main objective of this study
is to assess to what extent the financing of professional homecare nursing services
can/needs to be changed from the current scheme to an alternative financing scheme
taking into account the relative patient case-mix. Different data collection approaches
were used. First, the Belgian financing system for home nursing is described, mainly
based on documents describing the regulations. Second, the financing systems for home
nursing in a selection of Western-European countries were compared on a general
level. Third, a literature review was performed on scales and instruments that could be
used to support case-mix funding in home care and/or nursing. And finally, the opinions
of Belgian stakeholders on the current financing regulations were explored by means of
stakeholder dialogues.
The approach chosen has particular limitations:
This report uses a rather narrow approach on the concept of home nursing determined
by the existing financing framework of home nursing at the federal level in Belgium. In
the Belgian context, as comparable to the German situation, the financing of home
nursing activities is embedded in financing regulations in which nursing activities are
considered as complementing or supporting medical activities. Professional home
nursing is organised and financed by the NIHDI. Welfare services such as family support
services are organised and financed on a community level. Hospital nursing is organised
and financed on a Federal level by the Ministry of Public Health. This division of political
competencies and financing regimes makes the debate complex as nursing and care
topics play at the crossroad of these domains. On many issues the delineation between
home nursing and home care is difficult to make in daily practice, as demonstrate both
the stakeholder dialogue on the Belgian situation and the cross-national comparison.
This study did not elaborate on the overlap, complexity and differences between the
financing mechanisms on different politic levels in Belgium. A study with a broader scope
(in which home nursing is embedded in the broader field of home care, long term care
or chronic care) would possibly enable to develop a more overall picture on the vision
and position attributed to respectively home care and home nursing in the Belgian
health care sector, taking into account nursing care in (post-) acute situations and
nursing within the domain of chronic general and specialised care. It is clear though that
a discussion on the public financing is de facto also closely related to the debate on the
intended organisation of home care and home nursing.
The study uses the perspective of financing of providers. It did not address the question
of patients’ accessibility and equity. It has to be recognized though, that changes to the
reimbursement schemes or changes in the provision of services can have a major impact
on equity and accessibility issues for the target populations. The practical conditions of
this research (time and resources) did not allow to analyse the (potential) impact of
changing financing and organisation regimes for the patient. Due to the hybrid and
fragmented financing structure of home nursing, it is difficult to assess the level of copayment
because the provision of home nursing is on the borderline with the provision
of home care and help. The same or similar activities, sometimes by the same providers,
is financed both along the lines of health care and long term care including social care.
The financing of home nursing is relative free when it is situated in the health care but it
is less so in the long term care regimes. In Germany when the lump sum budgets,
allocated according to dependency degree, are exhausted, the financing needs to be
topped up with out-of-pocket payments or reliance on social assistance. In the Dutch
long term care insurance, there is a co-payment for home nursing dependent on the
age, income (of the total household) and living situation. In the UK, public financing of
home care is tested.