Le financement des soins infirmiers à domicile en Belgique - KCE

64 Financing of Home Nursing KCE reports 122
• Address the shortage of nurses through adequate payment and making the
home nursing profession more attractive.
6.3.5.2 The activity level in home nursing
The current organisation of home nursing allows that (part-time) employed nurses
developed a self employed practice of home nursing. Every nurse in Belgium is entitled
to be registered by the NIHDI and perform home nursing even with a minimum activity
level. A particular problem was mentioned with regard to nurses who combine their
hospital job with a job as part-time self-employed nurse doing some “cherry-picking” of
performing some series of interventions to patients at home. This raises some concerns
both with regard to the continuity of care and the quality for offering a holistic nursing
approach. It could be considered to introduce a minimum level of activity of the home
nurses and connect it to the financing regulations. In Germany as well as in France,
there is a requirement that nurses in home care should have at least two years
(Germany) and three years (France) of experience before they are allowed to practice
as a self-employed nurse.
6.3.6 Adaptation of the current funding system, the readjustment or the
calculation of new tariffs
One of the major critics of the currently used nursing nomenclature in Belgium is that
tariffs do not cover the actual costs and that it lacks the use of more objective
parameters to adjust the fees. Tariffs reflect the dynamics of a consensus-process rather
than objective estimates of covering costs. Moreover, the current nomenclature of
nursing interventions is very complex and not sufficiently specific to identify nursing
interventions. Billing rules are complex (ex: rules to prevent the combination of nursing
interventions) and have inconsistencies (see also chapter 2).
6.3.6.1 Techniques to calculate and define tariffs
The main objective of a revision of the nurses’ nomenclature is to adjust tariffs in order
to avoid patient selection and to have a good correspondence between costs and tariffs.
Also adequate reimbursement for patients from the hospital with a need for
instruments or material that is not available in the home setting should be taken into
account in setting the right tariff 4 .
Foreign initiatives to adapt and modernise medical nomenclatures as in France 67-70 and
the United States could be inspiring on a methodological level to adapt the home
nursing nomenclature.
A first technique, used in France and in The United States is the positioning of medical
work of each act compared to other interventions, first within the same specialty
(cardiology, pneumology, paediatrics, etc.) then between specialties. The principle is to
choose an intervention, which will be the reference for the positioning of all other acts.
This is usually a common intervention, not too complex and which varies slightly
according to clinical situations. The assessment of the reference intervention is made by
experts. The evaluation is based on various criteria such as the length, the technical
complexity, the stress and the intellectual effort. Evaluations are conducted during
expert meetings, leading ultimately to consensus. Beyond the medical work, the cost of
the practice (vehicles, fuel, equipments, compress, etc.) has been also assessed. After
this evaluation, the fee is the sum of the medical work and the cost of the practice. The
existence of both values allows the adaptation of one element, independently of the
other (for example the adaptation of the value reflecting the cost of the practice due for
example to higher cost of fuel but no adaptation of the work value).
A second relatively complex technique consists in adjusting tariffs on the basis of actual
costs. Cost studies can be conducted in full costing or in direct costing 71 . Cost studies
require a cost study in the whole sector or in a sample of home nursing organisations in
order to calculate costs of each nursing intervention. This technique requires a good
information system providing two types of information: (a) resources consumed and (b)
activity produced with these resources.