Thomas Rousseau
NIHDI - COOPAMI
2
Thomas Rousseau
NIHDI - COOPAMI
A Belgian cooperation platform www.coopami.org
What
i’m
going
to
talk
about
…
Social
security
Social
assistance
Social
protection
Presentation:
•
only
on
social
security
in
the
strict
sense!
•
focus
on
the
Belgian
health
care
insurance!
Contributif
What
i’m
not
going
Usefull
information
•
Report
of
the
European
Observatory on
Health
Systems
and
Policies:
–
Gerkens
S,
Merkur S.
Belgium:
Health
system
review.
Health
Systems
in
Transition
,
2010
.
•
Websites:
–
National
Institute
for
Health
and
Disability
Insurance:
ww.riziv.fgov.be
–
The
B.
Health
Care
Knowledge
Centre:
www.kce.fgov.be
–
FPS
Social
Security:
www.socialsecurity.fgov.be
•
E
‐
for questions:
The
Belgian
health insurance
I.
Social security in Belgium
II. Financing of the compulsory
health insurance
III. Systems of payments
IV. Basic principles of the Belgian
health insurance
V. The management of the
health insurance
VI. The future?
VII. Summary
1. SOCIAL SECURITY IN
BELGIUM
Social
Security
in
Belgium
(1)
•
Social security
is a public system of social
assurances.
•
3
systems
of social security
Salaried
persons
79%Selfemployed
persons
12% Civil servants 6%Its own reglementation
Its own social
protection
Its own methode of
financing
Social
Security
in
Belgium
(2)
•
The
social
security
contains
different
sectors:
Salaried
persons
Selfemployed
persons
Civil servants
Insurance
for
accidents
at
work
X
X
Insurance for
occupational diseases
X
X
Unemployment
X
Insurance
for
medical
care
and
benefits
X
X
X
Pensions
X
X
X
Family
benefits
X
X
X
Annual vacation
X
X
Social
Security
in
Belgium
(3)
Source: SPF Sécurity Sociale
24%
27%
Expenditures
of
social
security
2010
Soins de santé Incapacité de travail Chômage Politique du marché du travail Pensions de vieillesse Pensions de survie Allocations familiales
Autres risques couverts
TOTAL:
94.122.580.923
EUR
Health
care
Social
Security
in
Belgium
(4)
•
Who is
collecting and
managing
the
money
for the
social security?
2
collecting
institutions
National
Social
Security
Office
(NSSO)
Salaried persons
and
fonctionnaires
National
Institute
for
the
Social
Security
of
the
Self
‐
Employed
(NISSE)
Self
‐
Employed
persons
Salaried persons
(1)
Salaried persons
National
Social
Security
Office
Sector
Employee contribution (%) Employer's contribution (%) Total (%) Medical care 3,55 3,80 7,35 Indemnités 1,15 2,35 3,50 Unemployment 0,87 1,46 2,33 Pensions 7,50 8,86 16,36 Family benefits 0,00 7,00 7,00 Accidents at work 0,00 0,30 0,30 Occupational diseases 0,00 1,00 1,00Salaried persons
(2)
National
Social
Security
Office
Social
contributions
Government subsidies
Alternative financing
Why?
limit government subsidies
reduce employers' contributions
NIHDI
66%
10,3%
23,7%
Distributionof financial resources between sectors
according to the real needs
Globalisation of the financial resources and
management of incoming funds
NPO
2. Self
‐
Employed
persons
Self
‐
Employed
persons
(1)
The self-employed pay their quarterly social security contribution to the
social insurance fund they are affiliated with
. The contribution is
calculated on the self-employed person's net
professional labour income in
the third calendar year ('
reference year
') preceding the year for
which the
contribution is due.
Professional
income per
bracket
Amount of
the
contribution
Up
to
12.597,43
€
692,86
€ per
quarter
Between 12.597,43
€ and
54.398,06
€
22%
of
net
professional
income
Between 54.398,06
€ and
80.165,52
€
14.16%
of
net
professional
income
More
than 80.165,52
€
0
€
Self
‐
Employed
persons
(2)
58,40%
23,15%
18,08%
0,37%
Financing
Social
Contributions
Government
subsidies
Alternative
financing
Others
2.
FINANCING OF
THE
COMPULSORY HEALTH INSURANCE
Financing
of
compulsory
health
insurance
SOURCES
(millions
€)
%
Social
contributions
+
government
subsidies
+
alternative
financing
26.493.101 91,14%
Retirement
contribution
951.013
3,27%
Car
insurance
474.282
1,63%
Fire
insurance
179.660
0,62%
Tax on profit of
pharmaceutical
companies
262.940
0,90%
Complementary hospital insurance
124.564
0,43%
Internationale
conventions
382.163
1,31%
Other sources
200.276
0,69%
Expenditures
Reimbursement
of
health
care
services
26.853.110
Internationales
conventions
637.268
Administration
costs
sickness
funds
891.951
Administration
costs
NIHDI
102.658
Other
expenditures
583.012
total
expenditures
29.067.999
Partial objectives
29,09% 21,31% 17,70% 9,24% 4,67% 4,46% 3,28% 2,70% 2,43% 2,18% 1,60% 0,98% 0,17% 0,13% 0,06% Médecins Hôpitaux Médicaments Maisons de repos Infirmiers Solde Dentistes Implants Kinésithérapeutes Rééducation Dialyse Bandagistes et orthopédistes Audiciens OpticiensHealth care sectors
Doctors
Hospitals
Pharmaceutical
How
do
we
fix
yearly
the
reimbursement
budget
of
health
care
?
Fixation
of
the
budget
•
Budget =
The annual amount necessary for the health
insurance to cover the reimbursement of health
care for the Belgian population.
Fixation
of
the
budget
Budget
T
‐
1
+
Growth norm(%)
+
Inflation T
(%)
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
=
Budget
T
The
real growth norm
1995
‐
2000
1,50%
2001
‐
2004
2,50%
2005
‐
2011
4,50%
2012
‐
2013
2,00%
2014
‐
3,00%
Evolution
Fixing the annual global budget objective is therefore not
subject to a vote in parliament, but the parliament can change
the growth norm
New initiatives and
savings
measures
Year
initiatives
savings
measures
net
effect
cumulative
net
effect
2004
121.770 ‐221.988 ‐100.218 ‐100.2182005
44.108 ‐399.761 ‐355.653 ‐455.8712006
270.836 ‐132.172 138.664 ‐317.2072007
156.846 ‐38.016 118.830 ‐198.3772008
415.356 0 415.356 216.9792009
191.842 ‐139.317 52.525 269.5042010
393.955 ‐201.825 192.130 461.6342011
109.883 ‐100.000 9.883 471.5172012
6.505 ‐494.857 ‐488.352 ‐16.8352013
696 ‐269.816 ‐269.120 ‐285.9553.
SYSTEMS
OF
PAYMENTS
Systems
of
payments
(1)
Health care providerHealth insurance fund Insured / Patient
Systems
of
payments
(2)
•
Generally
organized
as
self
‐
employed
professionals
–
The general practitioner : works mainly in private
practice
–
The medical specialist: can work in health
institutions (mostly hospitals) and/or on an
ambulatory basis in private practice
•
Therapeutic freedom
for physicians
•
A significant proportion of health care
providers are paid on a
fee
‐
for
‐
service basis
•
No
referral system
between GPs and other
specialists
Systems
of
payments
(3)
•
Private
non
‐
profit
‐
making
organizations
with
a
public
interest
mission
–
They
are
grouped
into
5
national
associations
according
to
their
political
or
ideological
background
:
1. National Alliance of Christian Mutualities 2. National Union of Neutral Mutualities 3. National Union of Socialist Mutualities 4. National Union of Liberal Mutualities
5. National Union of the Free and Professional Mutualities
–
Their
role
in
the
compulsory
health
insurance
system
1. Ensure the reimbursement of health‐care expenses and the provision of an alternative income in case of incapacity to work. 2. Control of conformity with the legal rules (advisory physicians) 3. Provide information to their members and the health care
providers
•
The compulsory insurance package and the social contribution
rates are identical for all funds
Health
insurance
Systems
of
payments
(4)
Insured /
Patient
•
2
obligations:
1. Affiliate or register with a
health
insurance
fund
2. Paying
social security contributions
•
Freedom of
choice:
–
health care provider (+ right to a
second opinion)
Systems
of
payments
(5)
1. A
system
of
reimbursement
Health care provider
Health insurance fund Insured / Patient
Reimbursement
=
Official
fee
– Co
‐
payment
the
full
fee
Systems
of
payments (6)
2. A
system
of
third
party
paying
insurance
allowance
bill
Health
insurance fund
Insured /
Patient
Co
‐
payment or
user
charge
Hôpital
Financing of
Health
insurance
fund
70% of the expenditures 30% on basis of a distribution key
NIHDI
Insured / Patient (± 11.000.000)
Health insurance funds
4. Basic principles of the Belgian health insurance
Universal
coverage
•
3
dimensions
>
99%
11.000
Nomenclature codes
± 80%
Compulsory
insurance
•
A
compulsory
insurance
1. All working people have to pay
social security
contributions
and equal a minimum amount
2. All entiteld persons must
affiliate
with a sickness
fund (NO
RISK
SELECTION
!)
+ pay a small flat
Solidarity
1. Horizontal
solidarity: between good and bad risks
2. Vertical
solidarity: between rich and poor
Sociale
contributions are
related to
the
income and
do
not depend on the
health
risks !!!
3. National
solidarity:
all the citizens ar paying as a
whole
Equity
(1)
•
Protection measures
for lower socioeconomic groups
–
A
system
of
increased reimbursement
•
widows,
disabled
persons,
pensioners,
orphans
and
some
unemployed
persons
•
all persons
under a
fixed income limit
–
Maximum
Billing
(MAB)
•
System
making
sure
each
family
does
not
have
to
spend
more
than
a
maximum
amount
on
some
health
costs.
•
Exact
amount
depends
on
the
family
income.
Equity
(2)
•
Other protection measures
–
Special
Solidarity
Fund
•
Additional
reimbursement
for
patients
with
a
rare
illness
or
who
need
a
very specific treatment
–
Fixed payments to patients who
can
be
expected
to
have
high
medical
expenditure
•
For
chronically
ill
patients
•
For
incontinence material
•
For
palliative treatment
at
home
5. The management of the health insurance
The
management
of
the
health
insurance
NIHDI
National
union of
health insurance
funds
Health
insurance
funds
NIHDI
(1)
•
The
National
Institute
for
Health
and
Disability
Insurance
•
Since 1963
•
A public social security institution under the responsibilities
of the Minister of Social Affairs (and Public Health)
–
Extended
management
autonomy
–
Management
agreement
•
Manages and supervises the compulsory health care and
benefits insurance
NIHDI
(2)
FPS
Health
Ministère
NIHDI
Public
social
security
institution
•
Preparation and realisation of
public
health policy
The organization and financing of health care institutions
The organization of health professions
The emergency medical
•
General organization and financial management of the
compulsory health care and benefits insurance
Organize reimbursement of medical costs Elaborate legislation and regulation
Monitor the evolution of health care spending
Inform health care providers, sickness funds and the insured, and to ensure they apply the legislation and regulation correctly
Organize the negotiations between the different actors involved in compulsory health insurance
NIHDI
(3)
CEO & Deputy CEO Health care Departement Benefits Department Medical Evaluation and Inspection Department Administrative Inspection Department General Support DepartmentsFund for Medical Accidents Cell Communication Cell Modernisation Cell Datamanagement
Cell Expertise &
COOPAMI
Safety information Prevention service
Internal audit
General
Managment Committee
± 1350
staff members
The
collective
negotiation
process
in
the
health
insurance
(1)
•
Stakeholders
NIHDI
Government Salaried employees and self‐employed workers Sickness funds Health care providers EmployersThe
collective
negotiation
process
in
the
health
insurance
(2)
•
The
object
The
global orientations on
health
policy
and
global
budget
General
reglementation
The
reimbursed medical services
– the
nomenclature
The
collective
negotiation
process
in
the
health
insurance
(3)
Workgroups
Technical councils
Conventions
and
agreements commissions
General
Council
Committee for
Health
Care
Insurance
Minister of
social
affaires
•
Negotiation bodies
Sectoral negotations Preparatory negotations General managementThe
collective
negotiation
process
in
the
health
insurance
(4)
Example:
The
budgetary
process
Negotiation body
Conventions and agreements
commissions
Health Care Department of the
NIHDI
Budget Control Committee
Health Care Insurance Committee
General Council
Conventions and agreements
commissions
Mission
Determination of needs
Carries out technical estimates
Identification of potential
economy measures
Suggestion of a global budget objective
+
its breakdown into partial objectives Decision on a global budget objective +
its breakdown into partial objectives
Negotiation of conventions and
6. THE
FUTURE?
The
objectives
of
the
Belgian
health
care
system
Maintaining
financial
sustainability
Assuring health
care
quality
Increasing
accessibility
The
long
‐
run
challenge:
accommodating
increasing
expenditures
(1)
0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5 1980‐1990 1990‐2000 2000‐2007
Trends in health expenditure in Belgium, 1990–2007
Total health expenditure GDP
The
long
‐
run
challenge:
accommodating
increasing
expenditures
(2)
•
Factors
driving
health
care
spending
in
past
decades
–
Policy decisions to
enlarge acces
–
Demand for better quality health
care
linked to
growing income
levels
–
Technology evolution
•
Futur chalanges
–
Increased
health
‐
threatening
lifestyles
•
Men:
49%
overweight
‐
14%
obese
•
Women:
28%
overweight
‐
13%
obese
–
Increasing
of
chronic
diseases
–
Improved
wellbeing
and
a
better
standard
of
living
–
Growth
and
progress
of
new
technologies
and
treatment
The
long
‐
run
challenge:
accommodating
increasing
expenditures
(3)
0,0% 5,0% 10,0% 15,0% 20,0% 25,0% 1997 2001 2004 21,4% 23,1% 18,7% 8,6% 10,6% 10,6%
Percentage
of
households that had
to
postpone medical care
because
of
financial reasons,
by income level
< 750 euro 750 ‐ 1000 euro 1001 ‐ 1500 euro 1501‐2500 euro > 2500 euro Total
The
long
‐
run
challenge:
accommodating
increasing
expenditures
(4)
Low
expenditures
High
expenditures
Growth of
private
alernatives Further extensionof the collective system
•
What to
do?
• Increasing cost‐awareness of the players
• Increasing the efficiency
• Increasing the prevention
• Rewarding quality
