Soins maternels intensifs (Maternal Intensive Care) en Belgique - KCE

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8 Maternal Intensive Care in Belgium KCE Reports 94 To help them work together in this context a list of maternal pathologies was made for which procedures of consultation were considered necessary concerning conditions and circumstances for intra-uterine transfer. I. Given the Belgian context it is recommended that any mother has the freedom to choose the accredited MIC-service she wants if she needs maternal intensive care as well as to choose the accredited NIC-service where she wants her child(ren) who need(s) neonatal intensive care, to be treated. In other words, it is not allowed that any M, N* en P* makes exclusive contracts for transferring these patients among each other. 1.3.3 NIC-services in Belgium (1996) A few years after the publication of the WENZ-report, a new Royal Decree changed the existing accreditation criteria of the n-service into the N*-function, while the Nservice were replaced by the NIC-service. At the same time, the new P*-function (regional perinatology) was created. This new function combines the NIC-service and MIC-service which is both located at the same hospital campus. The new Royal Decree implements almost all recommendations proposed by the WENZ-commission. The most important exception is that this R.D. does not specify the list of maternal pathologies for which written procedures concerning consultation between the chief-clinicians of M-service, the N*-function and the P*-function is deemed necessary. The Royal Decree of August 1996 also specifies, as recommended, that the MIC-service should be staffed at all times with at least 2 FTE midwives, who are trained on a regular basis in the care of high-risk pregnancies. Since then, the hospital budget is adjusted for the extra personnel costs in the Mservices with an accredited MIC-service. 1.3.4 Perinatal Hospital Care (1996) Hospitals with accredited MIC and NIC-services treat patients that need more intensive care than hospitals with accredited M and N*-services only. They need to be reimbursed separately for these intensive care treatments. This assumes that parameters are found that measure differences in workload and other cost-drivers. This assumes also that mothers and newborns can be classified between those who need intensive care and those who don’t. The Belgian Federal Science Policy Office (previously known as the Federal Office for Scientific, Technical and Cultural Affairs) has financed a research project to develop a more appropriate financing system for perinatal hospital care in Belgium that promotes efficiency and equity in this field. The study (promoters: L. Cannoodt and A. Vleugels) focussed primarily on the financing of neonatal services. In one chapter of this study efforts were made to classify patients that need maternal intensive care versus other maternal care. The list of high-risk pregnancies, developed by the WENZ-commission, (see above 1.2. H.) was translated into codes of ICD-9-CM. As it turned out, it was not possible to determine from the ICD-9-CM codes only whether the patient needed to be transferred to a MIC-service or could be treated in a regular M-service facility. The same analysis was attempted using the minimal nursing data-set ( M.V.G. – R.I.M.) and the physician reimbursement fee schedule (nomenclature). It was concluded that these two classification systems were also not useful to distinguish between MIC– and Mpatients. Therefore, the Obstetrical experts of the FPZ-commission recommended that the Chief Obstetrician of each M-Service should make written agreements with the Chief Obstetrician of at least one MIC-service about the conditions and circumstances where consultation and/or transfer of patients to a MIC-service is recommended, based on the following (translated) classification:
KCE Reports 94 Maternal Intensive Care in Belgium 9 1.3.4.1 Pathologies for which consultation is recommended: 1. Pre-existing disorders which might influence pregnancy and/or delivery negatively or might be negatively influenced by pregnancy and/or childbirth: • Diabetes and/or serious endocrinologic disorders like thyroid pathology etc.; • Renal insufficiency; • Cardiac disorders, with pulmonary hypertension or mitral suffering; • Haematologic disorders (oncologic, thrombotic disorders, haemoglobinopathy); • Respiratory disorders with respiratory limitations (insufficiency, blood gas ). 2. Based on obstetric anamneses: • Recurrent preterm birth, PPROM (Preterm Premature Rupture Of Membranes); • Trophoblastic disorders (Choriocarcinoma); • Recurrent miscarriage; • Genetic risks or risk for malformation. 3. Pathology developed or discovered during pregnancy: • Suspicion of foetal malformation(s) and/or growth retardation whereby early treatment is recommended; • PPROM between, 24 and 30 weeks; • Iso-immunisation during pregnancy; • Multiple pregnancies (> 2); • Maternal malign disorders and serious infections (e.g. hepatitis). 4. During or shortly after childbirth: unexpected complications need to be treated in loco. 1.3.4.2 Pathologies for which consultation and possible transfer is recommended 1. All situations of increasing seriousness under 1+: • Pregnancy-induced hypertension with serious impact on mother and child; • Serious hypertensive disorders before 32 weeks or high risk for foetal distress before 32 weeks (PPROM, preterm labour, placenta praevia); • Maternal pathology or trauma requiring intensive care or specific expertise (e.g. serious infections: hepatitis, ARDS, pancreatitis,…). 1.3.5 MIC-Financing Each general hospital receives a budget for paying most of the operating costs (physician remuneration not included). In the year 1998 each hospital with an accredited MICservice, received for the first time an extra amount to pay for the additional required FTE of midwives with experience in high-risk pregnancies who work in the MIC-service. Since 1999 each general hospital is first assigned a number of points for part of the hospital budget (the so-called B2), based on a series of parameters expressing case-mix and hospital characteristics. Then the value of each point is calculated nationally, and finally the budget for each hospital is calculated. Each hospital with an accredited MIC-service gets 3.75 points per accredited MIC-bed. For the other M-beds the hospitals get only 1.46 points per calculated appropriate bed [adjusted for average length of stay per DRG (Diagnostic Related Group)]. In other words the additional MIC-budget is worth 2.29 points per accredited MIC-bed. One point is now worth 20,239.10 € (situation July 2006).
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