Le financement des soins infirmiers à domicile en Belgique - KCE

82 Financing of Home Nursing KCE reports 122
From about 1200 theoretical cost values, 31 homogenous Groups of Tariffs are
established where for each tariff group the cost of providing care would not access +/-
10 € of the average tariff set 80 .
Financing SSIAD
Financing IDEL
The financing of the NHCS (SSIADS) is based on a daily fixed price per place taking into
account average nursing time required. It is entirely covered by the National Health
Insurance Fund (CNAM). The budget is based on the number of “installed” places,
which can be different from the number of “authorised” places (the theoretical planned
maximum) number. This budget is supposed to cover all expenses of the service, the
remuneration of the personnel, the operation costs (local, transport, administration of
the service). With this budget, SSIADs can employ salaried nurses and nursing aids, and
appeal to independent nurses, paid fee-for-service. The reimbursement rate of nursing
care is over 90% for a long period (89.5% for medical acts and 94.5% for nursing acts).
In October 2000, the nurses' fee schedule was changed to introduce the new services
provided by the nurses administering care under the PSI (assessment of needs and
drafting of a nursing plan, the visits necessary to its implementation, the clinical
monitoring visits). In France, authorized procedures are organised into a relative
hierarchy and are attributed a coefficient with respect to a unit of measurement, known
as a 'key letter'. In this first version, the new procedures were attributed a specific
coefficient based on the existing nurses' 'key letters' 78 .
In June 2002, the fee schedule was changed again, and a new 'key letter' was created for
the visit during which the nursing care plan is established. This symbolic change is
presented by Convergence Infirmière as a first step towards the official recognition of
the concept of "nurse's visit" (the existing key letters specifically referred to the
technical or personal care provided, but not the more "intellectual" component of the
activity). The forms that nurses must fill in were published in October 2002. In the
codicil of the National Agreement published in 2003, the DSI is included in the new
convention framework and a new incentive (Professional Practice Contract) has been
added. In this lump sum financing model a huge part of care activities is done by care
personnel instead of nurses.
In a recent study the financing system of the SSIAD is evaluated e . The financing system
caused substantial problems of either under-provision for dependent persons when the
budget of the SSIAD does not allow additional dependent patients, or otherwise deficits
for the service. The study proposes a new system based on the cost of the structure on
one hand, and the cost of the individual care to be provided (‘les coûts terrain’). This
cost can be based on dependency, morbidity, need for care by a nurse, availability of
informal care and others.
The IDEL is financed on the health insurance means by way of conventions between the
sickness funds, the state and the nursing professional organisations. Sickness funds pay
fees for services within constrained budgets. Tariffs for fees-for-service are fixed with a
key letter. Technical acts are supposed to require 16 minutes of nursing time whereas
nursing acts are supposed to require 30 minutes.
Part of the remuneration is also paid for travel costs (both fixed prices and relative
prices linked to kilometres),
IDEL working with SSIADS transmit at the end of each month a list of all acts
performed per patient, their quote in the nomenclature list, the related tariffs, and the
related expenses in order to be paid.The fee for service system leads to a “supplier
induced phenomenon” in order to guarantee the income of the professional. It has been
observed that in area’s with a shortage of home nursing, the majority of activities of
IDEL are technical activities.
e Chevreul K., Eon Y., Com-Ruelle L., Lelouarne J.- F., Lucier S. Le coût de la prise en charge des patients
en SSIAD et ses déterminants : vers quelle tarification ? Séminaires : Mardis de l'IRDES
(http://www.irdes.fr/EspaceRecherche/SeminairesHistorique2008.html)