Le financement des soins infirmiers à domicile en Belgique - KCE

60 Financing of Home Nursing KCE reports 122
6.3.2 Financing nursing interventions
According to the typology of Jegers et al. (2002) 13 , a fee-for-service payment system (as
the main bulk of the nursing interventions are paid) is a largely variable system as home
nurses increase their returns by producing more services. It has two principal benefits:
access of care is guaranteed as well as provision of the best care available, at least if
tariffs are high enough. Therefore governments should monitor/control that the tariffs
for single nursing interventions account for the marginal costs of that intervention.
Stakeholders mentioned though that tariffs of basic nursing interventions in the Belgian
system, such as hygienic nursing care, wound care and injections, do not account for the
workload and the time required to carry out these interventions. Neither do current
tariffs account for the relative value of nursing interventions within the total
nomenclature.
An important backdrop of a fee-for-service system is the supply-induced effect.
Authorities should limit supply induced nursing care provision in order to cap the
expenses. Assigning a predefined budget is a powerful tool.
But discussion issues of a different nature rise too. In a fee-for-service system, the
nursing activity is reduced to a sum of individual nursing interventions. Moreover, it has
been mentioned that the current nomenclature does not include all nursing
interventions. The development of the nursing profession has demonstrated that
(home) nursing is more than the sum of the separate interventions. It requires to assess
the complete home care environment for each patient on self-care skills, cognitive
abilities, psychological and social environment.
Based on the insights of nursing theories, some stakeholders of employee nursing
organisations argued to limit fee-for-service financing to simple and well-defined nursing
interventions, such as an injection, simple wound care, etc., Lump sum financing
according to dependency levels could then be used for situations aiming at a more
holistic nursing approach.
A particular category is the group of specific technical nursing interventions (nursing
interventions for intravenous or sub-cutaneous infusion, parenteral nutrition, epidural
anaesthesia, intra-thecal anaesthesia, installation of a permanent catheter or
material/needle for medication administration in an implantable medication infusion
device). Stakeholders agree that these more specialised technical nursing interventions
are rather well financed in the current regulations, although that it lacks insight to what
extent the fees cover real costs. Moreover, this part of the fee for service financing
leads to questions about cherry-picking (see infra).
A debate of a different nature is the extent to which hospitals and home nursing
providers can work in a complementary way in the home environment of a patient. The
international comparison (e.g. France, The Netherlands, UK) learns that the financing
system for highly specialized nursing care is partly embedded in the model of hospital
financing rather than in the modalities of home nursing. Hospitals are allowed to
perform or outsource these activities (if they want) to home nurses, but remain
responsible for the quality. This decision is embedded in a thorough discussion on the
notions of post acute and specialised care, on the changing roles of health providers,
and is to a large extent also an issue of acceptance of which actor operates on a
particular sector of the “market”.
6.3.3 Financing per number of patients
The current Belgian financing system is not using a capitation financing mechanism.
Neither is it advocated by Belgian home nursing stakeholders. In a capitation system,
periodical lump sum payments are made (usually annual) per patient under the
supervision of the nurses during a certain period (usually a year). This payment is done
irrespective of the number of performed activities and contacts 13 and when capitation
was mentioned in the stakeholders’ discussion there was no advocate for it.