Le financement des soins infirmiers à domicile en Belgique - KCE

66 Financing of Home Nursing KCE reports 122
Many of the principles that are mainly applied to medical doctors can be applied as well
to other professionals as home nurses.
Key messages
• An important backdrop of a fee-for-service system is the supply-induced effect.
Moreover, in a fee-for-service system, the nursing activity is reduced to a sum
of individual nursing interventions, while (home) nursing is considered more
than the sum of the separate interventions.
• Stakeholders agree that more specialised technical nursing interventions are
rather well financed in the current Belgian regulations. It lacks insight though
to what extent these fees cover real costs.
• Moreover, this part of the fee for service financing leads to questions about
cherry-picking of nurses combining their hospital job with a job as part-time
self-employed nurse performing only specialized nursing interventions to
patients at home. This raises concerns both with regard to the continuity of
care and the quality for offering a holistic nursing approach.
• A debate could be considered on the extent to which hospitals and home
nursing providers can work in a complementary way in the home environment
of a patient for highly specialized nursing care. This can impact on the choice
for financing regulations (activities partly funded under hospital regimes).
• The current Belgian financing system is not using a capitation financing
mechanism. Neither is it advocated by Belgian home nursing stakeholders.
• A per diem lump sum financing gives incentives to providers to reduce costs
per patient-day, while it challenges the policy makers to take accompanying
measures to guarantee accessibility, quality and affordability for patients.
• Regarding the current control procedures, concerns rise on the different
meanings given to the needs of patients: home nurses focus on care relationship
and assess the needs from that perspective, while NIHDI control agents focus
on patients functional competence.
• Stakeholders seem to agree to that part of their financing can be based on
(better defined) dependency categories or resource utilization groups. There
are mixed opinions on the use of the potential alternative assessment
instruments based on issues of usability, validity and reliability with regard to
the purposes of each of these instruments.
• Characteristics of the nurses such as the qualification, level of expertise and
experience could be considered. The financing principles will induce some
effects. If nurses are considered as equally competent and price indifferent,
there will be an incentive to hire the less costly nurse. If they are paid
differently, a discussion will be needed on the criteria used to justify different
payments.
• The logistic structure and the so-called back-up services of the different types of
home nursing providers (large organisations, self employed) should be
considered in the debate. However, this does not imply that financing should be
adapted to the specific cost structures of each individual provider.
• There is a current paradox between the financing regulations 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.