Le financement des soins infirmiers à domicile en Belgique - KCE

KCE Report 122 Financing of Home Nursing 65
• Accounting data means computing total expenditure (consumables, salaries,
equipment depreciation, etc.) per home nursing provider.
• Activity data include all nursing activities performed for each patient.
Furthermore, an allowance for indirect costs should also be made.
Providing accurate data is currently a problematic issue in Belgian home nursing.
The aim is to allocate costs on activity with cost drivers (for example length of time per
act or weight per act) and to obtain a cost per patient based on the consumption of
activity. Each patient can afterwards be aggregated according to his diagnosis, his profile
of dependency, and so on. This technique is mainly developed in hospitals in Belgium 69,
72
.
Some other practical considerations could be taken along too. The French
nomenclature 67-69 describes a procedure avoiding the registration of partial acts. The
approach used is well described 73 . All interventions made in the practice are identified
and coded. Each intervention is paid taking into account the nursing workload (or
medical workload) and the costs per act (cost of the practice). Nursing or medical
interventions are classified based on relative values of each act compared to relative
values of others in the nomenclature 70 .
6.3.7 The organisation
Organisations or services providing home nursing range from independent selfemployed
nurses, over smaller groupings of self-employed nurses, over larger home
nursing organisations –some with close connections to sickness-funds. The main issues
with regard to financing principles are connected to differences between large
organisations and self-employed nursing (individuals or small groupings). The cost
structures for these different types or organisations are quite different, and a policy
discussion is needed to what extent these need have to be considered in the financing
principles. The logistic structure and the so-called back-up services of the different types
of organisations is an issue that can be included in the debate on providing home
nursing and financing for it. These discussions are connected to issues of quality of care.
Home nurses need to address issues such as 7/24 continuity of care, phone permanence
for emergencies and availability of nurses for questions of general practitioners and
patients. Questions should also be debated on the competencies for nursing situations
requiring particular knowledge. Moreover, it should be discussed on how financing of
home nursing can give incentives for continuous education, to deal with basic clinical
infrastructure (patient record, electronic agenda and communication) and ICT support.
In the stakeholder discussions, self-employed home nurses criticized that the current
subsidies for specific costs of services for home nursing are limited to services
consisting of at least 7 full-time-equivalents. Stakeholders argued that smaller practices
or associations of self-employed home nurses should also receive financing for
organisational measures which contribute to continuity of care.
It was also argued that different costs structures resulting from social tax differences
between self-employed and employee-nurses should be taken into account by the
financing system.
6.3.8 The results/ performance
The current Belgian financing mechanisms for home nursing do not take account for
results or performance. There was quite a consensus that the financing system and
accompanying control procedures should give more incentives for quality of care. One
of the problems mentioned was the current paradox between the regulation and the
societal objectives to develop more independence and autonomy of the individual
patients. The current financing schemes have the paradoxical effect that nursing
organisations striving for this autonomy are sanctioning themselves financially. Care
providers who are able to prevent the deterioration of patient status, who are putting
effort in teaching and training to get the patient independent, etc. are expected to
obtain financial incentives if they reach these goals. The benefits, pitfalls and feasibility of
systems for pay-for-performance has recently been described in a KCE-report 74 .