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54 Hyperbaric Oxygenation Therapy KCE Reports 74 As mentioned by Fife et al., 130 for the treatment of lower-extremity lesions, rather than complete healing of a lesion, the objective today is more often a partial healing by granulation to the point that epithelization can continue without further hyperbaric therapy. As a consequence, achieving the complete healing category might not be the best objective for cost-effective treatment of patients with HBOT. 130 4.5 CONCLUSION HBOT may provide several benefits such as reducing length of hospital stay, reduction in amputations, improvement in patients QoL, reduction in outpatient care, etc. According to several authors, this could result both in increasing benefits and decreasing costs, resulting in a cost saving treatment. For example, it seems that HBOT could be cost-effective in the treatment of diabetic wounds. All studies, however, show limitations for both incremental cost and benefit calculations. Therefore, they can only be seen as an indication that HBOT may be a cost-effective treatment. They do not provide good evidence that HBOT is a cost-effective treatment. The suggestion that HBOT could be clinically effective, could improve QoL, and could reduce health care costs in certain indications highlights the need for further large multi-centre trials to find out whether or not this is the case. While evidence data would be collected, good cost data should also be gathered. Incremental costs and benefits which are part of both the short- and long-term treatment pathway should be taken into account. As long as good qualitative evidence and cost data are lacking, good qualitative economic evaluations can not be performed. Key points • Being an adjunct to standard therapy, HBOT is associated with increased (initial) treatment costs. • Even though potential harms caused by HBOT appear to be small, it is a waste of valuable resources to use HBOT for conditions for which it is not effective. • Economic evaluations currently are based on insufficient data and therefore have important limitations for both the incremental cost and benefit calculations. • It is not possible to estimate cost-effectiveness of HBOT without good data on effectiveness, costs and quality of life. • HBOT might be effective, improve QoL, and reduce costs in certain indications. Therefore, it deserves further attention and there is need for large multi-centre trials to gather both short- and long-term evidence and cost data.
KCE Reports 74 Hyperbaric Oxygenation Therapy 55 5 THE BELGIAN SITUATION 5.1 HISTORICAL CONTEXT Up to the beginning of the nineteen sixties there was no organized emergency care in Belgium. With the Law of July 8, 1964 on urgent medical assistance, the government aimed to start up the “Dienst/Service 900”. Under this law, the Ministry of Health donated a large number of standard and reanimation ambulances to the hospitals during the subsequent years. Ten hospitals (mostly teaching hospitals) also received a hyperbaric monoplace chamber. At that time, the predominant indications were acute, i.e. CO intoxication and decompression illness, for which one or a few sessions were sufficient. Therefore, the ministry, which already had financed the hyperbaric equipment itself, introduced in 1972 a relatively low fee for a maximum of two sessions. 131 5.2 CURRENT RIZIV/INAMI NOMENCLATURE AND REGULATION 5.2.1 RIZIV/INAMI fee-for-service system in general Under the RIZIV/INAMI fee-for-service system, hospitals register all specific medical acts and procedures in order to receive direct reimbursement from the national health insurance for that part of the cost that is refundable by social security. This system also determines what the patient will need to pay out of pocket. The whole set of rules for this registration and those payments is laid down in a so-called ‘RIVIZ/INAMI nomenclature’ that is in constant evolution. 5.2.2 RIZIV/INAMI nomenclature for hyperbaric oxygen therapy 5.2.2.1 Overview of codes In the RIZIV/INAMI nomenclature, reimbursement is provided for the first and second day through the following reanimation billing codes for ‘installation and supervision’ of HBOT. There is no financing for the following days (See Table 11). Table 11. Fee-for-service codes RIZIV/INAMI Code Amb/Hos Definition 212516 Amb Installation of and supervision on oxygen therapy in hyperbaric chamber 212520 Hosp (regardless the number of sessions): The first day 212531 Amb Installation of and supervision on oxygen therapy in hyperbaric chamber 212542 Hosp (regardless the number of sessions): The second day Amb: ambulatory; Hosp: hospitalized Source: https://www.riziv.fgov.be/webapp/nomen/ (accessed on 29 November 2007) 5.2.2.2 Regulation on the application In theory, HBOT can only be charged when the patient is in a life-threatening situation (source: RIZIV/INAMI). There are specific conditions attached to this reimbursement, and hyperbaric oxygen can, for example, not be cumulated with a number of other procedures, such as neurodiagnostic, polygraphic and polysomnographic investigations, surveillance on hypothermy, etc. A copy of the detailed regulation can be found in appendix (in Dutch). 5.2.2.3 Invoicing practices in hospitals The nomenclature code does not explicitly restrict HBOT to specific indications. As a result, it allows for broad interpretation. In daily practice, HBOT centres apply the codes in various ways. Some centres only charge the RIZIV/INAMI for hospitalized patients, because the invoicing is only allowed in life-threatening situations, which is often not the case for ambulatory patients.
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