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50 APPENDICES Physiotherapy KCE reports vol. 40 C. THE ICF IN REIMBURSED PHYSIOTHERAPY CARE 1. FULL ICF CODING As observed in the international comparison of reimbursement schemes for outpatient physiotherapy care, no system based on ICF codification was found to be in use for the analysed countries. This could, in part, be explained by the still somewhat experimental nature of ICF codification, which only received formal WHOapproval in 2001. Statistical use of ICF is still largely under development, which may impede professionals familiarity with the classification system. The main advantage of ICF lies in its application as a cross-disciplinary multipurpose framework for comprehensive understanding of various health states. As such, it makes for a promising clinical tool allowing to compare (and hence evaluate) medical effectiveness across health care systems and between settings. However promising ICF may prove as a scientific lever to lift quality of care, considerable difficulties arise in handling ICF as a means to regulate reimbursement. A general principle underlying the ICF coding is its aspiration to exhaustiveness, in spite of the obvious fact no coding system will incorporate all possible individual patient cases. The number of separate ICF measurements per person can relate to 1.424 scored items in all. Even assuming that for this set of items a qualitative binary criterion ( bad/good ) is used, this would engender an abstractly high value of theoretically possible patient case categories 16 . A minimal coding approach would require 34 (dichotomously scored) items 17 , still allowing for an impressive continuum of theoretic patient cases (2 raised to the power of 34, equating to 17.179.869.184). As reimbursement schemes seek to reconcile patient case differentiation and organisational feasibility, an ICF codification base seems an unwieldy and therefore unlikely option. All the more so, it is not clear how ICF coded patient cases would be linked to reimbursement categories. These categories imply measurement in monetary terms and would primarily rely on quantifying intermediary variables such as required number of treatment episodes, set episode duration and episode frequency. One would assume the link between ICF coded patient cases would ideally be established through empiric observation of evidence-based protocols. As our literature search indicated, even for a limited set of pathologies, the traced evidence is not univocal and sometimes missing. Expert consensus findings applicable to Belgium may offer a way out here. A further argument corroborating the case against the use of ICF codification in physiotherapy care lies in the intrinsic nature of adequately scoring patient case items. Not only would this be a time-consuming activity on the part of physiotherapists, but proper scoring practices would require some form of blind referral scoring as practitioners both scoring and treating the same patient would be exposed to considerable financial incentives to engage into all imaginable forms of up-coding . Consequently, this would bring about ICF creep , similar to experiences in DRG-financed care settings and blunt the promising tool ICF could grow out to be. One could, of course, counter-argue that peer provider comparison checks would suffice. However, as ICF codification incorporates patient case mix specifications in great detail, it is hard to imagine any straightforward ex post control mechanism. In summary, reimbursement schemes for physiotherapy care based on full ICF codification are unwieldy from an organisational point-of-view, uncertain from a scientific standpoint and bear the risk of encumbering the future usability of ICF coding as a clinical tool. 2. PARTIAL ICF CODING As suggested by our research, partial ICF coding could be implemented on a pathology-specific basis, limited to (global) measures summarizing overall observations for 1 or 2 ICF dimensions. As indicated by the literature search body and activities dimension are best covered by existing functional tests. Certain specific disadvantages should be taken into account following such an approach: The intrinsic rationale for ICF codification is corrupted as inter-pathology comparability is lost. 16 In the quoted example this value equates to 2 raised to the power of 1.424 (assuming the absence of exclusive dependence between scoring outcomes). 17 One-digit level codification: 8 body functions, 8 body structures, 9 performance and 9 capacity codes.
KCE reports vol. 40 APPENDICES Physiotherapy 51 The current fit of existing tests for global ICF dimensions is often incomplete for varying pathologies. This could regard both the absence of an exhaustive list of item tests or of overall global scoring measures. Questions regarding the link between scoring outcomes and reimbursement terms remain. The gain in taxonomic simplicity brought on by globalizing dimension scores would be partially offset by adding an initial pathology-based classification. As shown in our prospective research the ten most frequent pathologies only accounted for 43,3% of attributed treatment sessions. As some of these defined pathologies should be further subdivided for obvious reasons (e.g. presence of orthopaedic implants into anatomic categories: hip, knee, etc.) it should be clear that any top-down pathologybased classification would require a manifold of base categories if some degree of overall real life exhaustiveness is aspired to. The general concern for proper coding practices and related scientific relevance of ICF tools also prevails in a partial coding system. Following the exposed arguments, our conclusion reads that the disadvantages full ICF codification as a reimbursement framework entails, also apply to schemes resorting to partial ICF coding: unmanageable organisational complexity, scientific uncertainty (at present) and deterioration of ICF tools as clinical standards. 3. CONCLUSION As stated by our research most analysed fee-for-service schemes favour an approach based on a rudimentary classification of pathologies into broad reimbursement categories that correspond to a set number of entitled treatment episodes. Exceptional patient cases warrant complementary treatment on an ad hoc basis through additional administrative measures (follow-up prescriptions, etc.). Further observed developments regard care capitation and product bundling. These measures aim to simplify billing procedures and make third-party expenditures more manageable. Consequently, observed reimbursement schemes appear to be driven by an impetus toward organisational simplicity rather than attested clinical effectiveness. As our discussion on ICF coding aimed to demonstrate, this approach is justified from a third-party payer perspective. Even more so, applying ICF as a reimbursement reference could be detrimental to its intrinsic scientific relevance. Therefore, it should be clear that the significance of ICF as a policy tool must be restricted to its use as a complementary and strictly scientific means, in time perhaps helping to fill a crucial void in assuring the quality of physiotherapy care.
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